This study examined whether socio-demographic and -economic factors influence 30-day readmissions for conditions such as chronic obstructive pulmonary disease, pneumonia, acute myocardial infarction and heart failure.

Download this field guide that lists various approaches used by Quality Improvement Organizations to help improve transitions of care within different communities across the United States.

Download this fact sheet from the TMF Quality Innovation Network to help patients better manage their Chronic Obstructive Pulmonary Disease (COPD).

In this video, Dr. Erin Carlson, from The University of Texas at Arlington, discusses the root causes of disparities and inequities in the health care system that contribute to emergency department usage.

This Jan. 2, 2024, article from The Dallas Observer highlights the success of the RIGHT Care Unit, which consists of an interdisciplinary team of first responders and health care professionals who respond to 911 calls from individuals experiencing behavioral health crises across the Dallas metro area.

Patients can use this resource to help determine when to call the doctor (the Yellow Zone) and when to seek emergency help (the Red Zone).

This recorded presentation defines chronic obstructive pulmonary disease (COPD) and shares resources to support patients in managing this disease. Kim Jungkind, a quality improve specialist with the TMF Innovation Network, also provides ideas for reducing COPD readmissions.

Listen and learn from nationally recognized experts in four, 15-minute podcasts about the importance and effectiveness of starting buprenorphine treatment for opioid use disorder in emergency departments.

This article discusses ways to improve patient transfers from one facility to another. Effective transfers helps ensure that all patients have access to quality care.

Hospital readmission rates for people with conditions targeted by the CMS Hospital Readmission Reduction Program (HRRP) have not changed, according to results of a study published in BMC Public Health. In this article, researchers describe their data collection methods, summarize current conditions and offer strategies for reducing hospital readmissions.

This article addresses a new ruling from the Centers for Medicare and Medicaid Services (CMS) that promotes high-quality patient support and rewards hospitals that provide the safest care.

This article examines recent research about how new technologies, such as artificial intelligence, can be used in a post-discharge patient engagement program. New technologies could address factors beyond social determinants of health (SDOH) and address emotional, behavioral and other barriers to recovery.

In this recorded, one-hour webinar, Jessica Wauson, from the American Heart Association, shares evidence-based guidelines for treating heart failure. Also featured: a review of the patient assessments and education tools that patients can use to successfully manage their condition.

Read about the 30-day Care Transitions Intervention® (CTI®), which was created with reducing the number of preventable readmissions among Medicare beneficiaries.

Work with your department leadership team to complete the following assessment. Each item relates to care transition elements that should be in place for a program to improve care transitions within your facility. This Care Transitions Implementation Assessment is supported by published evidence and best practices.

The Process Improvement Discovery Tool helps Partnership for Community Health member hospitals provide safer patient care. The tool helps health care providers identify process improvement opportunities for reducing readmissions.

Research shows that more than 20% of Medicare beneficiaries discharged from a hospital to a skilled nursing facility will return to a hospital within 30 days, costing Medicare more than $4 billion per year. These returns are often due to potentially preventable conditions, such as dehydration, infections, medication errors, and unaddressed social needs. This toolkit provides an overview of care coordination best practices to avert hospital readmissions.

This webinar recording describes a hospital and community health center collaboration that works to address the underlying needs of the patients who are most likely to become frequent visitors to hospital emergency rooms. The goal is to improve their quality of life outcomes and reduce readmissions while supporting substance users in central Houston.

In the health care industry, the error risk is high when patients are transferred from one entity to another, such as from a hospital to a short-term rehabilitation center. This new issue brief discusses the potential for errors during all transitions in care. The brief identifies how diagnostic errors can be made and provides strategies to reduce these errors.

Actively engaging patients in their care prior to discharge can ensure patients get the right care at the right time. This article discusses how educating patients about the benefits and programs available to them can help them manage their care needs.

This March 14, 2023 recorded webinar provides information about the new guidelines on chronic care management (CCM). The presesntation is given by Ellen Berra, Wisconsin Physician Services Government Health Administrators, a Medicare Administrative Contractor, MAC. Berra and TMF's Ardis Reed, MPH, RD, LD, CDCES then answer participants' questions in this one-hour event.

This May 16, 2023, recorded webinar features Matt Zavadsky, the chief transformation officer at MedStar Mobile Healthcare. Zavadsky, also an emergency medical technician, explains what it means to be a "mobile health care provider," which transforms the traditional role of emergency medical services into more than merely a conveyance method. If you have questions or want a copy of the handout, please contact us at communityhealth@tmf.org.

Documenting medication history, before a patient is discharged from a hospital emergency department (ED), and then reconciling medications upon discharge, is an effective way to reduce medication discrepancies, according to recent study.

A recent survey shows that nearly 100% of hospital providers will likely send referrals to post-acute care providers who can accept electronic orders. This article discusses that finding and others from a new survey of more than 130 hospital and physician entities.

When you or a loved one gets sick or injured, and your health care provider's office is closed, you might immediately head for the emergency room. That may not be the best place for your care, however. Take a few minutes to review this resource and make a decision about where to go for care based on your symptoms.

This article describes the successful quality improvement and community education efforts at Community Hospital, McCook, NE. Community Hospital is a critical access facility that provides advanced care to more than 30,000 people throughout southwest Nebraska and northwest Kansas.

Providers can use this form when they want to refer patients to cardiac rehabilitation.

This report, from the National Center for Health Statistics, shows that rates of Emergency Department (ED) visits for any mental health disorder were highest among non-Hispanic Black adults (96.8) compared with non-Hispanic White (53.4) and Hispanic (36.0) adults. Adults made an average of 774,508 mental health-related ED visits per year from 2018 to 2020, accounting for 12.3% of all ED visits made by adults.

This abstract describes the results of a study that examined the effectiveness of interventions designed to safeguard patients when transitioning from the hospital to home.

This article discusses how a person's wellbeing is a predictor for 30-day readmission rates. Patients with the highest wellbeing are less than half as likely to be readmitted than patients with inconsistent or poor wellbeing.

Download this list of interventions you and your hospital staff can use to help to decrease hospital use for Medicare beneficiaries who are identified as super utilizers.

Numerous care transition processes have been shown to reduce 30-day readmissions in clinical trials. The objective of this study was to examine the relationship between the number of evidence-based transitional care processes used and the risk-standardized readmission rate. This study may be used to help support recommendations to reduce avoidable readmissions in hospital settings.

This measure for hospitals to evaluate communication for transitions of care during emergency department (ED) transfers is particularly relevant for critical access hospitals (CAHs). The measure is included in the Medicare Beneficiary Quality Improvement Project (MBQIP). The goal of MBQIP is to improve the quality of care provided in CAHs by increasing quality data reporting that will drive quality improvement activities based on the data.

This new topic guide features resources and information regarding the Rural Emergency Hospital (REH). The guide describes the contribution different payers make to rural healthcare, payment systems and related facility types in rural areas and how payment policies impact rural facilities' financial sustainability.

The results of this survey study suggest that rural hospitals, Critical Access Hospitals and Safety Net Hospitals are not doing more and, in some cases, are engaging in fewer strategies to address the Social Determinants of Health of their vulnerable populations, especially regarding community partnerships.

Access to health care is limited in rural Texas. The mobile clinic operated by Beaumont-based TAN Healthcare aims to close that gap.

A public health crisis is growing more acute in rural America, affecting individuals with both Medicaid and Medicare (the “dually eligible”). Rural residents suffer a “rural mortality penalty,” with rurality and poverty as predictors of mortality. Among the social determinants are hospital closures, workforce shortages, migration to urban centers, inadequate transportation and limited access to broadband internet. Perhaps most affected are cultural minority populations and indigenous peoples.

In this video, Kimberly Jungkind, a health care quality improvement specialist with the TMF Quality Innovation Network-Quality Improvement Organization, discusses how to reduce readmissions for patients with congestive heart failure (CHF). Jungkind shares resources that support patients with CHF to better manage their condition, and she offers innovative ideas for helping patients with CHF buy and cook foods that are heart healthy.

Recent research finds that, on average, rural populations are older than urban populations, and the proportion of older adults is increasing more quickly in rural communities. While most older adults want to stay in their own homes as they age, older adults living alone in rural areas can be socially isolated and lonely. n, loneliness, and unsafe living conditions.

This article announces the Center for Advancing Rural Health Equity (CARHE) inauguration. CARHE will focus on identifying and addressing persistent health disparities through collaboration and will engage with the community to better understand the issues people face when accessing health care.

This fact sheet provides an overview of telehealth policies for Federally Qualified Health Centers (FQHCs). The fact sheet covers originating and distance sites, reimbursement and services outside the FQHC. It includes a chart of FQHC Medicaid telehealth reimbursement eligibility by state.

This toolkit compiles evidence-based and promising models and resources to support organizations implementing emergency planning, response and recovery efforts in rural communities across the United States.

This article describes the role of State Offices of Rural Health (SORHs) in relation to state Primary Care Offices (PCOs), highlighting New Hampshire's Office of Rural Health and Primary Care. The article also discusses collaboration between SORHs and other state offices and the unique challenges of supporting rural health.

This recently updated topic guide provides resources and information about healthcare and population health issues in remote and sparsely populated areas. It also features a new FAQ on health-related infrastructure challenges in rural areas.

On Jan. 25, 2023, TMF QIN-QIO specialists discussed strategies for reducing readmissions and increasing patient and family engagement. The attendees also learned about care transitions, the TMF Patient and Family Engagement Network and the Partnership for Community Health Network.

Download this list of interventions you and your hospital staff can use to help decrease emergency room visits from Medicare beneficiaries at short-term hospitals, critical access hospitals and inpatient psychiatric facilities.

Work with your department leadership team to complete the following assessment. Each item relates to care transition elements that should be in place for a program to improve care transitions within your facility. This Care Transitions Implementation Assessment is supported by published evidence and best practices.

Work with your department leadership team to complete the following assessment. Each item relates to care transition elements that should be in place for a program to improve care transitions within your facility. This Care Transitions Implementation Assessment is supported by published evidence and best practices.

The TMF Quality Innovation Network, under contract with the Centers for Medicare & Medicaid Services, designed this change package to provide strategies to improve the quality of care transitions.

The transition of care for medically complex patients to and from a skilled nursing facility is critical; however, care providers in these settings have identified several significant challenges. This article discusses those challenges and offers some suggestions for overcoming them

Watch this video to learn how to implement lasting solutions to help your facility reduce avoidable readmissions.

The purpose of this video is to highlight health care quality improvement interventions hospitals can implement to help manage super utilizers in the health care system.

Calculate by QxMD developed this online calculator to help hospitals identify patients who are more likely to be readmitted. Once hospitals identify those patients, hospital discharge staff can give those patients needed instructions when discharged from the hospital to another care setting or home to help lessen the likelihood that they will be readmitted to the hospital.

Scroll down on this webpage to find free resources you and your hospital staff can use to develop or strengthen your care transitions plans and processes.

Agency for Healthcare Research and Quality developed this document for health care staff to use to interview patients about their care experience and why they were readmitted.

The Center for Health Care Strategies, Inc. developed this multi-page questionnaire to help health care providers determine where their patients need assistance with a variety of medical and social health care needs.

This one-page document the Where for Care campaign developed helps guide the reader through developing a care plan before an actual medical emergency takes place.

The American Academy of Family Physicians created this handout to help care teams understand social determinants of health and how to develop a team-based care approach to identify specific patient needs and how to address those needs.

The American Academy of Family Physicians created this two-page fillable PDF document to allow a care team member to work directly with a patient to document the social determinants that may influence their health needs.

The AAMC created this five-page checklist for care team members to use to help prompt patients to provide more information about themselves, which can help identify areas of need that have historically not been addressed in the traditional clinical setting.

Download this infographic to view what The Joint Commission considers are the eight tips for high-quality patient hand offs.

Download this PDF of a PowerPoint presentation developed by the Denver Health Alliance that explores different care models to address super utilizers’ needs.

Download this one-page list of interventions you and your hospital staff can use to help reduce 30-day hospital readmissions.

Researchers at the Boston University Medical Center developed and tested a set of activities and materials for improving the hospital discharge process, which they called the Re-Engineered Discharge (RED). Research showed that the RED was effective at reducing readmissions and post-discharge emergency visits. RED consists of a set of 12 mutually reinforcing actions; outlined in this toolkit.

This easy-to-use checklist from the Centers for Medicare & Medicaid Services (CMS) is for patients and their caregivers preparing to leave a hospital, nursing home or other care setting.

This tool from the Centers for Medicare and Medicaid Services includes a list of items that must be assessed during the on-site survey, in order to determine compliance with the Discharge Planning Condition of Participation.

Hospitals can use this Tracer Tool to survey and evaluate their processes for reducing patient readmissions, with the goal of providing safe, high-quality patient care.

A checklist for hospitals to review current interventions, or initiate new ones, to aid readmissions reduction in your facility.

The Care Transitions Program provides insights and tools for how to improve quality and manage risk during care hand-overs.

This Microsoft Excel spreadsheet audit tool prompts clinical or quality staff members to review a list of factors commonly attributed to preventable hospital readmissions. The review can help you understand the kinds of barriers patients, families, and providers face during preparation of discharge to the post-hospital transitional care period and the circumstances leading patients to return to the hospital.

Trauma-informed care acknowledges that understanding a patient’s life experiences is key to potentially improving engagement and outcomes while lowering unnecessary utilization.

This one-page audit tool prompts clinical or quality staff members to review a list of factors commonly attributed to preventable hospital readmissions. The review can help you understand the kinds of barriers patients, families, and providers face during preparation of discharge to the post-hospital transitional care period and the circumstances leading patients to return to the hospital.

Use this form for patients being readmitted to psychiatric care to determine the factors leading to readmission.

The Medications at Transitions and Clinical Handoffs (MATCH) toolkit was developed to help facilities improve their medication reconciliation process. This toolkit provides a step-by-step guide to help health care providers ensure patients are properly educated about the medications they have been prescribed to help avoid medication errors and patient harm.

Internists/primary care physicians and nurses: Provide this document to your patients, which includes more information to help them ascertain when to call your office for help or when to go to the emergency room for a range of conditions, including shortness of breath, heart failure, complications with diabetes and more. Patients: Use this document to help determine when to call your physician for help or when to go to the emergency department for assistance.

The Agency for Healthcare Research and Quality, in coordination with Boston University Medical Center, has developed an online Re-Engineered Discharge (RED) tool kit. RED has been shown to be effective in reducing readmissions and post-hospital emergency department visits.

This tool is designed to help facilities complete an assessment of care transition elements that should be in place for a program to improve care transitions within its facility. This Care Transitions Implementation Assessment is supported by published evidence and best practices. In Spanish.

This tool is designed to help facilities complete an assessment of care transition elements that should be in place for a program to improve care transitions within emergency department. This Care Transitions Implementation Assessment is supported by published evidence and best practices. In Spanish.

This tool is designed to help facilities complete an assessment of care transition elements that should be in place for a program to improve care transitions within its facility. This Care Transitions Implementation Assessment is supported by published evidence and best practices. In Spanish.

TMF Quality Innovation Network, según el contrato con los Centros de Servicios de Medicare y Medicaid, diseñó este paquete para facilitar el cambio a fin de proporcionar estrategias para mejorar la calidad de las transiciones de atención.

Internists/primary care physicians and nurses: Provide this document to your patients, which includes more information to help them ascertain when to call your office for help or when to go to the emergency room for a range of conditions, including shortness of breath, heart failure, complications with diabetes and more. Patients: Use this document to help determine when to call your physician for help or when to go to the emergency department for assistance.