Since patients and their caregivers are at the center of healthcare services, it is critical that they feel empowered and informed as they transition between healthcare settings.
NC ACT has compiled the following information and resources to help patients and their caregivers better understand issues associated with transitioning from one health care setting to another and tools to help consumers as they navigate transitions.
Care Paths provides Advance Care Planning services to individuals and their families. Our services include educating individuals on the importance of advance directives, how to document their wishes, as well as how to ensure a person’s choices are communicated with the healthcare team. These services are a covered benefit under most insurance including Medicare. Care Paths’ goal is to educate adults years about advance directives years before they are ever needed. We work with clinics, facilities, hospitals, as well as meet individuals in our offices.
National Transitions of Care Coalition (NTOCC)
This site contains many patient and caregiver empowerment resources.
Person-Centered Approaches Supporting Successful Patient Outcomes for Recovery and Transitions (PASSPORT) TOOL
This tool was developed by the NC Division of Aging and Adult Services to provide information to consumers about the hospital discharge process.
Next Step in Care Tools for Family Caregivers
Supported by the United Hospital Fund, this website includes a variety of provider and caregiver resources and checklists. Patient/family materials are available in English, Spanish, Russian, and Chinese.
The Care Transitions Program
Helping patients and families get their needs met during care transitions.
Your Discharge Planning Checklist
CMS developed a checklist that prompts patients and caregivers to ask questions about key discharge planning topics including their likely care needs, the options for continuing care, post-discharge care instructions, community-based resources, and more.
Useful Tips for Managing Medication (YouTube Video)