English | 繁體中文 | Español | Русский | Tagalog | Tiếng Việt

Care Transitions Taskforce – Projects

Care Transitions Taskforce – Projects 2018-02-06T09:37:55+00:00


  • Partnership with Information Systems to improve discharge documentation and communication
  • Development of medical student and housestaff curricula on care transitions resources and best practices
  • Standardization of primary care team communication
  • Dissemination of data dashboards
  • Care Transitions Discharge Worklist – used to help with discharge planning and timely access to data for improvement purposes

(L-R) Larissa Thomas, Liz Davis, Will Huen, and Jack Chase brainstorm innovative solutions to care transitions at a Taskforce meeting. Photo credit: Karishma Oza/DHM.


  • Taking Accountability for Ambulatory Care Transitions (TAACT) collaborative
    • Primary care-based pilot utilizing complex care management teams for transitions work
  • Care Transitions Discharge Worklist – used to help with discharge planning and timely access to data for improvement purposes
  • Primary care standards working group
    • Post-discharge follow-up scheduling
    • Standardization of post-discharge follow-up content and documentation
    • Use of non-physician personnel to provide post-discharge follow-up
  • Medical Assistant post-discharge phone follow-up pilot
  • Zuckerberg San Francisco General Hospital Bridge Clinic – a post-discharge follow-up clinic

Marina Mancillas, a Medical Assistant, calls a patient to remind them of an upcoming post-discharge follow-up appointment at the General Medicine Clinic. Photo credit: Karishma Oza/DHM.


  • Zuckerberg San Francisco General Transitional Care Nursing program
    • Nursing-led, hospital-based intervention to prevent readmissions among patients ≥55 years with chronic obstructive pulmonary disease (COPD), myocardial infarction/heart attacks (MI), pneumonia & ≥18 years with congestive heart failure (CHF).

(L-R) The Transitional Care Nursing program: Tami Lenhoff (CHF Pharmacist), Michelle Schneidermann (Medical Director), Catheryn Williams (Transitions Care Coordinator), Tip Tam (Transitions Care Coordinator), and Richard Santana (Transitions Care Coordinator). Photo credit: Karishma Oza/DHM.


  • Discharge documentation
  • Medication reconciliation
  • CHF Transitions Pharmacist
  • Transitional Care Pharmacist
  • Patient education
  • Post-discharge pharmacist medication reconciliation visits
  • Readmission risk prediction: high-risk medications

(L-R) Dave Smith and Jeanette Cavano, leaders of the pharmacy transitions subgroup.Photo credit: Karishma Oza/DHM.