Care Transitions

This assessment tool from the Health Services Advisory Group can help determine what social support may assist with readmissions and care transitions.

Reducing preventable 30-day hospital readmissions is a priority for the Centers for Medicare & Medicaid Services (CMS). This toolkit from the Health Services Advisory Group identifies resources that will aid in improving care transitions and coordination across the continuum and serve as a guide to readmission prevention.

In this three-part video series, QSource and various guest speakers highlight the importance of having programs in place to support effective communication between health care settings.

The Seven Essential Intervention Categories Bundle, developed by the National Transitions of Care Coalition (NTOCC), can assist hospitals and patients/families in developing and implementing a transitions of care program.

This toolkit from the Health Services Advisory Group provides resources and an overview of care coordination best practices across the continuum best practices to avert hospital readmissions.

This recently updated guide shares information for rural communities to use in planning or expanding transportation options to help residents access rural health care services.

The U.S. Surgeon General’s 2023 advisory on loneliness put a spotlight on the profound impact that social isolation is having on the physical and mental health of American communities. In this conversation, the president and CEO of Meritus Health discusses their Care Callers program, which enlists volunteers to call and check in on patients who report experiencing loneliness with encouraging results.

To ease patients' transition from hospital to home and address bed capacity issues, Mass General Brigham has created a discharge lounge. The lounge serves about 125 "medically cleared" patients who are waiting for their transportation.

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.

This webinar reviews evidence showing that Social Determinants of Health increase the likelihood of a hospital readmission, and that patients are most at risk for readmission due to new medications or lack of resources. Early identification of patients most at risk for readmissions can reduce a preventable readmission.

In 2018, there were 3.8 million adult hospital readmissions within 30 days with an average readmission cost of $16,403. Read about strategies to help reduce the number of patient readmissions.

Designed to assist hospital leaders and stakeholders focused on quality, safety and care redesign in identifying root causes and solutions for preventing avoidable readmissions among racially and ethnically diverse Medicare beneficiaries.

In early 2021, Coryell Health, a 25-bed critical access hospital (CAH) in Gatesville, Texas, observed an increase in 30-day all-cause readmission rates each quarter during 2020. The Coryell team focused intervention efforts on the transitional care management department with the goal of reducing the readmission rate by 2 percent by June 2022

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.

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.

In this presentation, TMF staff discuss how health equity strategies may help organizations reduce hospital readmissions.

The Modified LACE (Length of stay, Acuity of the Admission, Comorbidities, and Emergency room visits in the past six months) Tool can be used to predict and prevent unnecessary hospital readmissions.

This guide has a checklist of important items to discuss with your health care team when being discharged from the hospital.

The purpose of this form is to help patients and their families talk with health care providers about a hospital admission.

The Medicare Learning Network developed this booklet that outlines transitional care services during the 30-day period, which begins when a physician discharges the patient from an inpatient stay and continues for the next 29 days. Medicare may cover these services to help a patient transition back to a community setting after a stay at certain facility types.

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.

This comprehensive toolkit from Stratis Health contains guidance and resources to support rural leaders in developing community-based palliative care services.

The Process Improvement Discovery Tool helps hospitals provide safer patient care by identifying process improvement opportunities for reducing readmissions.

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

INTERACT (Interventions to Reduce Acute Care Transfers) is a quality improvement program that focuses on the management of acute change in resident condition.

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

Project Re-Engineered Discharge, research group at Boston University Medical Center, develops and tests strategies to improve the hospital discharge process in ways that promotes patient safety and reduces re-hospitalization rates.

This change package is intended to support dialysis facilities and End State Renal Disease (ESRD) Networks in increasing the number of patients referred to transplant centers, evaluated for kidney transplantation and placed on transplant waitlists

This change package is intended to support dialysis facilities and End State Renal Disease (ESRD) Networks in increasing the number of patients using home dialysis modalities, which include peritoneal dialysis (PD) and home hemodialysis (HHD)

This webinar recorded in Spanish for Puerto Rico reviews evidence showing that Social Determinants of Health increase the likelihood of a hospital readmission, and that patients are most at risk for readmission due to new medications or lack of resources. Early identification of patients most at risk for readmissions can reduce a preventable readmission.

A Spanish for Puerto RIco version of a tool to help patients and their families talk with health care providers about a hospital admission.

Spanish for Puerto Rico version of a checklist of important items to discuss with your health care team when being discharged from the hospital.

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.