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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Transportation to Support Rural Health Care
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.
Web link    Date Added: 02/29/2024    Date Last Modified: Feb 29 2024 11:25AM  
Checking in on You: Addressing Loneliness With Care Callers
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.
Podcast    Date Added: 11/15/2023    Date Last Modified: Nov 15 2023 2:05PM  
Mass General Brigham's Discharge Lounge Provides Comfortable Care Transition
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.
Web link    Date Added: 11/15/2023    Date Last Modified: Nov 15 2023 2:26PM  
How to Reduce Chronic Obstructive Pulmonary Disease Readmissions
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.
Video    Date Added: 11/08/2023    Date Last Modified: Nov 29 2023 11:26AM  
Reducing Readmissions in the Vulnerable Population
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.
Video    Date Added: 06/29/2023    Date Last Modified: Jul 10 2023 9:40AM  
Stop Avoidable Readmissions
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.
Adobe PDF    Date Added: 05/24/2023    Date Last Modified: May 24 2023 5:16PM  
Guide to Reducing Disparities in 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.
Adobe PDF    Date Added: 05/08/2023    Date Last Modified: May 8 2023 5:55PM  
Coryell Health: Reducing 30-Day All-Cause Readmission Rates by Enhancing Care Transitions
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
Microsoft Word    Date Added: 03/23/2023    Date Last Modified: Mar 23 2023 11:29AM  
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: 01/17/2023    Date Last Modified: Jan 17 2023 6:13AM  
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: Feb 2 2024 5:39PM  
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: Oct 9 2023 4:50PM  
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: Mar 8 2023 2:37PM  
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: Apr 25 2023 9:02AM  
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  
Reducing Readmissions in the Vulnerable Populations (Spanish for Puerto Rico)
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.
Video    Date Added: 09/15/2023    Date Last Modified: Sep 15 2023 2:03PM  
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: Oct 10 2023 10:40AM  
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