Transitional Care & Pressure Ulcers Project Toolkit


Cross-setting interventions and setting-specific best practices for transitional care to prevent and/or treat pressure ulcers. Developed by an expert panel convened by a Joint Committee of the Oregon IHI Network and Oregon leadership of the Advancing Excellence in America’s Nursing Homes Campaign.

In 2007, the Oregon IHI Network and the Oregon leadership of the Advancing Excellence in America’s Nursing Homes campaign formed a Joint Committee to plan and develop cross-setting interventions for transitional care, with an initial focus on pressure ulcers. The Joint Committee convened an Advisory Panel of clinicians, educators, health plan representatives, and experts from regulatory and quality improvement agencies to

  • identify best practices for preventing or minimizing pressure ulcers in hospitals, nursing homes, community-based long-term care, and home health agencies
  • develop a handoff data set of pressure ulcer-related information that would accompany patients in transition from one setting to another

These tools, with support materials such as the Braden Scale for predicting pressure ulcer risk, were compiled in a toolkit and then pilot-tested in multiple care settings in four communities. The Joint Committee and its constituent organizations have endorsed the toolkit materials as support for efforts to improve pressure ulcer prevention and care in Oregon.


Table of contents


Convening an Advisory Panel


Questions for the Advisory Panel

Findings of the Advisory Panel

Provider tools


Oregon Best Practices


Best Practices


Nursing homes

Best Practices (updated 10/26/10 to reference MDS 3.0)


Community-based care

Best Practices


Home health & hospice

Best Practices


Other tools

Braden Scale for Predicting Pressure Sore Risk

Pressure Ulcer Definition and Stages

Summary of Pressure Ulcer Assessment Variables

Clinical Signs and Symptoms for Infection

Nutritional Care Guidelines

Pocket card: positioning, pressure points

Recommended Interventions to Prevent or Minimize Pressure Ulcers

Handoff dataset


The core version (updated 10/26/10 to reference MDS 3.0)

Pilot versions




The Dalles

Body diagrams

Handoff dataset audit

Community Tools

Introduction—Community implementation strategy

Building a team (around a safe table)


Work plan

Participation agreement

Confidentiality agreement

Completing a gap analysis (best practices audit/checklist)


Doing a case review


Case review outline

Case review ideas

Measuring prevalence (baseline and remeasurement)


Prevalence worksheet

Running a pilot


Handoff dataset pilot steps

Handoff dataset pilot process

Handoff dataset audit

Implementing within a community


Sample agenda for education day

Sample community policy and procedure

Joint Committee members

Acumentra Health

Oregon Alliance of Senior and Health Services (now LeadingAge Oregon)

Oregon Association for Home Care

Oregon Association of Hospitals and Health Systems

Oregon Health Care Association

Oregon Patient Safety Commission

Seniors and People with Disabilities