Medicine (SAEM) developed consensus standards to address the quality gaps in the transitions between inpatient and outpatient settings. The following summarized principles were established: 1.) Accountability; 2) Communication; 3.) Timely interchange of information; 4.) Involvement of the patient and family member; 5.) Respect the hub of coordination of care; 6.) All patients and their family/ caregivers should have a medical home or coordinating clinician; 7.) At every point of transitions the patient and/ or their family/caregivers need to know who is responsible for their care at that point; 9.) National standards; and 10.) Standardized metrics related to these standards in order to lead to quality improvement and accountability. Based on these principles, standards describing necessary components for implementation were developed: coordinating clinicians, care plans/transition record, communication infrastructure, standard communication formats, transition responsibility, timeliness, community standards, and measurement.

The '5As' model of behavior change provides a sequence of evidence-based clinician and office practice behaviors (Assess, Advise, Agree, Assist, Arrange) that can be applied in primary care settings to address a broad range of behaviors and health conditions. Although the 5As approach is becoming more widely adopted as a strategy for health behavior change counseling, practical and standardized assessments of 5As delivery are not widely available. This article provides clinicians and researchers with alternatives for assessment of 5As implementation for both quality improvement, and for research and evaluation purposes, and presents several practical tools they may wish to use. Sample instruments for tracking delivery of the 5As and related tools that are in the public domain are provided to facilitate integration of self-management support into clinical care. We discuss the strengths and limitations of the various assessment approaches. Promising and practical measures to assess the 5As exist for both quality improvement and research purposes. Additional validation is needed on almost all current procedures, and both clinicians and researchers are encouraged to use these instruments and share the resulting data.

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The American College of Physicians, Society of Hospital Medicine, and Society of General Internal Medicine convened a multi‐stakeholder consensus conference in July 2007 to address the quality gaps in the transitions between inpatient and outpatient settings and to develop consensus standards for these transitions. Over 30 organizations sent representatives to the Transitions of Care Consensus Conference. Participating organizations included medical specialty societies from internal medicine as well as family medicine and pediatrics, governmental agencies such as the Agency for Healthcare Research and Quality and the Centers for Medicare and Medicaid Services, performance measure developers such as the National Committee for Quality Assurance and the American Medical Association Physician Consortium on Performance Improvement, nurse associations such as the Visiting Nurse Associations of America and Home Care and Hospice, pharmacist groups, and patient groups such as the Institute for Family‐Centered Care. The Transitions of Care Consensus Conference made recommendations for standards concerning the transitions between inpatient and outpatient settings for future implementation. The American College of Physicians, Society of Hospital Medicine, Society of General Internal Medicine, American Geriatric Society, American College of Emergency Physicians, and Society for Academic Emergency Medicine all endorsed this document. Journal of Hospital Medicine 2009;4:364–370. © 2009 Society of Hospital Medicine.

This study reports on implementation of the CommunityRx system, a population health innovation that promoted clinic-community linkages via: a youth workforce (MAPSCorps) that conducted an annual community resource census; Community Health Information Specialists (CHIS) who supported cross-sector resource navigation; and a health information technology (HIT) for prescribing community resources. Between 2012–14, MAPSCorps identified 19,589 public-serving places in the 106mi2 implementation region. CHIS used these data to generate an inventory of nearly 15,000 health-promoting resources. The HIT platform was integrated with 3 electronic health record (EHR) systems at 33 clinical sites to map 37 prevalent health and wellness conditions to community resources; 253,479 personalized HealtheRx “prescriptions” were generated for approximately 113,000 participants. Participants found the HealtheRx very useful (83%); 19% went to a place they learned about from the HealtheRx. This study demonstrates the feasibility of using HIT and workforce innovation to bridge the gap between clinical and other health-promoting sectors.