Glossary and Resources
- Activities of daily living: Eating, bathing, dressing, toileting (being able to get on and off the toilet and perform personal hygiene functions), transferring (being able to get in and out of bed or a chair without assistance).
- AHRQ Health Literacy Universal Precautions Toolkit: Toolkit can help primary care practices reduce the complexity of health care, increase patient understanding of health information, and enhance support for patients of all health literacy levels.
- Caregivers: People who assist patients in receiving healthcare, social services, and facilitate activities of daily living; they frequently are relatives of the patient and are unpaid.
- Health systems: Organizations of healthcare providers that are contractually affiliated with one another or owned by the same organization. Health systems may include organizations of a single type of provider (e.g., hospitals or nursing homes) or bring together diverse types of providers (e.g., acute care hospitals, affiliated multi-specialty practices, ambulatory care centers) or serve low-income/low-resource populations (e.g., safety net, federally qualified health centers).
- Hospital: A facility that delivers a full spectrum of healthcare services to patients.
- Integrated care team: Includes all contributors who support patients care management: physicians, physician assistants, nurses, nurse practitioners, medical assistants, caregivers, pharmacists, social workers and mental health practitioners, and physical/occupational health.
- Integrated delivery systems: A network of organizations that provides or arranges to provide a coordinated continuum of services to a defined population and is willing to be held clinically and fiscally accountable for the outcomes and health status of the population served.
- Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation: The MATCH toolkit features a step-by-step guide for hospitals to improve medication reconciliation processes as patients move through the health care system.
- Multiple chronic conditions: Having two or more physical conditions that are chronic; having at least one chronic physical condition and at least one chronic mental health condition at the same time.
- Patients: Also called consumers; the people who receive healthcare services.
- Patient self-management: Self-management can be defined as the decisions and behaviors that patients with MCC engage in that affect their health.
- Primary care provider: A primary care provider (PCP) is a health care practitioner who sees people that have common medical problems. This person is most often a doctor. However, a PCP may be a physician assistant or a nurse practitioner.
- Re-Engineered Discharge (RED) Toolkit: This toolkit assists hospitals, including those that serve diverse populations, improve their hospital discharge process to reduce avoidable readmissions and post-hospital emergency department visits. A guide for patients and families, available in English and Spanish, was developed as part of the toolkit.
- Social services: Services that improve the well-being of individuals, families, or communities including, for example, transportation, housing, education, training, nutrition, wellness programs, senior support.
- Tools: Informational, educational materials or resources, including electronic resources (apps, Application Programming Interfaces [APIs], decision support tools) that contain and communicate actionable guidance for end users.
- Transitioning Newborns from NICU to Home: This toolkit includes resources for hospitals that wish to improve safety when newborns transition home from their neonatal intensive care unit (NICU) by creating a Health Coach Program, tools for coaches, and information for parents and families of newborns who have spent time in the NICU.
Mitchell SE et al. Care Transitions From Patient and Caregiver Perspectives. Ann Fam Med. (2018)