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Change Package and Tools

Introduction

Are you interested in making changes to improve care coordination for patients? The Home-to-Hospital-to-Home (H2H2H) Transitions Change Package was created to help primary care physicians and team members implement practice changes that improve care coordination for patients experiencing transitions in care. The change package tools were designed to work best in conjunction with quality improvement training to maximize their impact. 

The H2H2H process improvement change package was developed by the Alberta Medical Association (AMA) Accelerating Change Transformation Team (ACTT). Input was sought from patients who have lived experience in care transitions, and from providers with experience treating patients who require care coordination during transitions.

H2H2H Process Improvement Change Package

Wondering where to start? For a quick, at-a-glance overview, check out the H2H2H Change Package Summary. It is a compilation of guidance, resources, tips, and tools that support clinic-level implementation of the H2H2H guideline.

Below are a variety of products that will assist you in your efforts to improve care coordination.
  • The H2H2H Change Package is an introductory package of key information, best practices, and guidance that supports the H2H2H Transition Guideline. 
  • The H2H2H Change Package Summary is a quick but detailed overview of the information featured in the full H2H2H Change Package. 
  • The H2H2H Measurement Guide contains a sample list of measures (not exhaustive) to consider when looking to implement practice improvements for patients transitioning from home to hospital and back home again.
  • The H2H2H Evidence and Rationale document includes rationale for Potentially Better Practices. Grey and peer-reviewed literature are cited to support inclusion of the Potentially Better Practice. 
H2H2H Change Package
H2H2H Change Package Summary
H2H2H Evidence and Rationale
H2H2H Change Package Clinic Menu
H2H2H Change Package
H2H2H Change Package Summary
H2H2H Evidence and Rationale
H2H2H Change Package Clinic Menu
H2H2H Measurement Guide
H2H2H Glossary and Acronym List
H2H2H Measurement Guide
H2H2H Glossary and Acronym List

Change Package Tools

These are the tools that are referenced in the Change Package Summary

Improve the Patient Experience

Sequence to Acheive
Change
Sequence to Acheive
Change Blank Template
Patient Partner on Improvement Team Quality Improvement
Team List
Pre-Post Visit Scripts

Identify Paneled Patients

Panel Process Change Package Process Map Guide CII-CPAR Team Toolkit Find a Doctor website
Panel Processes Change Package Process Map Guide CII/CPAR Team Toolkit
(pg. 55)
Alberta Find a Doctor website


Optimize Care Processes

LACE Index Scoring Worksheet
PDSA Worksheet
Virtual care tools My New Steps: Getting Ready to Leave the Hospital
LACE Index Scoring Worksheet
PDSA Worksheet Post Discharge Follow-up Process Map Virtual care tools My New Steps: Getting Ready to Leave the Hospital


Standardize Documentation

Coming soon!

Coordinate Care in the Medical Home

Sample Huddle Checklist
H2H2H Roles and Responsibilities Guide Sample Huddle Checklist

Coordinate Care in the Health Neighborhood

Warm Hand Offs
Specialist Link
ConnectMD
Warm Hand Offs Specialist Link ConnectMD