NTOCC is a great resource, with sharable tools

The National Transitions of Care Coalition

The below is taken directly from their website;

The U.S. health care system often fails to meet the needs of elderly patient populations during transitions from one setting to another because care is rushed and responsibility is fragmented with inadequate communication between professionals, patients and care givers. In addition, too much responsibility and burden is placed on patients and their caregivers in initiating their own follow-up care with little understanding of their own conditions or the complexities of today’s health care system. There is increasing awareness among health care professionals and government leaders that the U.S. health care system must focus efforts on improving the coordination of care among the various practice settings to improve patient safety, quality of care and outcomes. NTOCC was founded to address this industry-wide problem through the collaboration of industry leaders and participants in identifying and developing implementable solutions. NTOCC seeks to raise awareness among consumers, health care professional and policy makers and provide tools they can use to improve transitions of care.