Care Transitions

This Readmissions Process Improvement Discovery Tool is meant to help hospitals provide safer patient care by completing an assessment to identify process improvement opportunities. Hospitals can use the results to develop specific strategies to address gaps and identify resource needs.

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

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 using home dialysis modalities, which include peritoneal dialysis (PD) and home hemodialysis (HHD)

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

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.