Care Transitions

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Better coordination of patient transfers among care sites can save resources and improve quality of care. Reducing avoidable readmission rates requires an evidence-based approach that incorporates communication, optimized workflows and institutional commitment to improving outcomes. Please note: on some web browsers, document links may automatically download to your computer rather than open up on your screen.

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Reducing Hospital Readmissions through Health Equity
In this presentation, TMF staff discuss how health equity strategies may help organizations reduce hospital readmissions.
Video    Date Added: 06/16/2022    Date Last Modified: Jun 16 2022 9:28AM  
Modified LACE Tool
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.
Microsoft Excel    Date Added: 04/06/2022    Date Last Modified: Sep 15 2022 2:49PM  
Hospital Discharge Discussion Guide for Patients and Families
This guide has a checklist of important items to discuss with your health care team when being discharged from the hospital.
Adobe PDF    Date Added: 04/04/2022    Date Last Modified: Apr 5 2022 1:54PM  
Hospital Admission Discussion Guide for Patients and Families
The purpose of this form is to help patients and their families talk with health care providers about a hospital admission.
Adobe PDF    Date Added: 04/04/2022    Date Last Modified: Apr 5 2022 1:55PM  
Transitional Care Management Services
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.
Adobe PDF    Date Added: 01/19/2022    Date Last Modified: Jan 19 2022 11:21AM  
CMS Hospital Discharge Planning Worksheet
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.
Adobe PDF    Date Added: 08/26/2021    Date Last Modified: Apr 14 2022 4:16PM  
Hospital Readmissions Tracer Tool
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.
Microsoft Word    Date Added: 05/12/2021    Date Last Modified: Apr 14 2022 4:12PM  
Rural Palliative Care Resource Center
This comprehensive toolkit from Stratis Health contains guidance and resources to support rural leaders in developing community-based palliative care services.
Web link    Date Added: 04/16/2021    Date Last Modified: Apr 16 2021 12:54PM  
Readmissions Process Improvement Discovery Tool
The Process Improvement Discovery Tool helps hospitals provide safer patient care by identifying process improvement opportunities for reducing readmissions.
Adobe PDF    Date Added: 03/24/2021    Date Last Modified: Jun 7 2021 3:04PM  
Preventable Readmissions Top 10 Checklist
A checklist for hospitals to review current interventions, or initiate new ones, to aid readmissions reduction in your facility.
Adobe PDF    Date Added: 03/08/2021    Date Last Modified: Apr 14 2022 4:18PM  
Interventions to reduce acute care transfers (INTERACT)
INTERACT (Interventions to Reduce Acute Care Transfers) is a quality improvement program that focuses on the management of acute change in resident condition.
Web link    Date Added: 01/20/2021    Date Last Modified: Jan 20 2021 2:21PM  
The Care Transitions Program
The Care Transitions Program provides insights and tools for how to improve quality and manage risk during care hand-overs.
Web link    Date Added: 01/20/2021    Date Last Modified: Apr 14 2022 4:21PM  
Project Re-Engineered Discharge (RED)
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.
Web link    Date Added: 01/19/2021    Date Last Modified: Jan 19 2021 3:07PM  
Increase Home Dialysis Use Change Package
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)
Adobe PDF    Date Added: 12/30/2020    Date Last Modified: Mar 15 2021 3:07PM  
Increase Kidney Transplantation Change Package
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
Adobe PDF    Date Added: 12/30/2020    Date Last Modified: Mar 15 2021 3:05PM  
Improve the Quality of Care Transitions Change Package
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.
Adobe PDF    Date Added: 09/30/2020    Date Last Modified: Mar 24 2022 11:05AM  
Hospital Admissions Discussion Guide for Patients and Families (PR Spanish)
A Spanish for Puerto RIco version of a tool to help patients and their families talk with health care providers about a hospital admission.
Adobe PDF    Date Added: 04/22/2022    Date Last Modified: Apr 22 2022 1:31PM  
Hospital Discharge Discussion Guide for Patients and Families (PR Spanish)
Spanish for Puerto Rico version of a checklist of important items to discuss with your health care team when being discharged from the hospital.
Adobe PDF    Date Added: 04/22/2022    Date Last Modified: Apr 22 2022 1:37PM  
Paquete para facilitar el cambio: Mejorar la calidad de las transiciones de atención, para Puerto Rico
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.
Adobe PDF    Date Added: 11/30/2020    Date Last Modified: Mar 24 2022 11:06AM