Hospitalization Reduction & Discharge to Community

This website has a variety of webinars, podcasts and resources to assist with promoting health care decision-making through advance-care planning conversations, education and preparation that help bridge disparity gaps for black Americans.

This post-discharge follow-up phone call tool from the Agency for Healthcare Research and Quality (AHRQ) enables nursing homes to identify and address a resident’s post-discharge needs and questions to avert readmissions. It also enables staff to assess a person's health status, check medicines, confirm future medical appointments and lab tests, and coordinate care with other health care providers.

These Best Practices Pocket Cards can be printed and laminated for education, training and reminders for staff in a variety of topics.

This resource provides details on how to run a Brown Bag Medicine Review. For new admissions, completing a reconciliation to what the resident’s home medications had been prior to the hospitalization could net valuable information on medications missed during an emergency admission and/or diagnoses that the hospital was unaware of, possibly leading to additional therapeutic interventions.

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).

Published by the Center for Practical Bioethics, this guide helps individuals and their families share meaningful conversations regarding end-of-life decisions. The Caring Conversations® Workbook and related materials describe the advance care planning process with a highly individualized focus. The materials include forms for documenting who can speak for you and what treatment preferences you may have.

This claims-based measure tip sheet provides an overview of the measure, including questions to ask, monitoring ideas and resource links.

Use this tool to identify community-specific resources to give to discharging residents/patients.

Download this document from the National Forum of ESRD Networks to help improve communication and the transition of patient care between a dialysis facility and a long-term care facility.

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.

This toolkit provides your team with actionable steps to decrease the number of hospital transfers of short stay residents.

ePrognosis is a set of calculators, decision tools and communication training to assist providers with evidenced-based information in determining the prognosis for their residents.

This presentation is from the Feb. 16, 2023, LTC Connect webinar, "Adverse Drug Events."

The Five Wishes Paper is a traditional printed advance care planning booklet to complete by hand. It meets requirements in nearly all states. If you live in one of only four states (New Hampshire, Kansas, Ohio or Texas) you can still use the Five Wishes Paper but may need to take an extra step. Available in 30 languages. Note: there is a small fee for use.

INTERACT® is an acronym for Interventions to Reduce Acute Care Transfers. See the "Version 4.5 Tools for Skilled Nursing." NOTE: A free account is required to access and download the tools.

This presentation is from the June 15, 2023, LTC Connect webinar, "Preventing ED Visits."

This video series follows a fictional family through the difficult process of making health care decisions for a loved one who did not make plans in advance. Each dramatization is followed by a didactic session where health care lawyers answer common questions about advance directives. The video is organized into seven segments that can be watched individually in any order or as one complete program.

This Feb. 16, 2023, LTC Connect recording focuses on the three commonly prescribed medications that can cause adverse drug events (ADEs) in nursing home residents. TMF Quality Innovation Network-Quality Improvement Organization specialists reviewed information on anticoagulant, diabetic and opioid medications, BEERS criteria and how ADEs can affect readmission and hospitalization rates.

This Aug. 17, 2023, recording explores how assessing fall risks and improving activities of daily living (ADL) performance can prevent emergency department (ED) visits and hospital readmissions. TMF Quality Innovation Network–Quality Improvement Organization specialists discuss appropriate interventions along with creative strategies that nursing homes can apply right away.

This June 15, 2023, LTC Connect recording discusses the top reasons for emergency department (ED) visits and how to recognize early changes in condition to minimize risk for nursing home residents. Additionally, a TMF Quality Innovation Network–Quality Improvement Organization (QIN-QIO) specialist reviewed strategies to reduce preventable ED visits and to engage residents and their families in the decision-making process.

This May 18, 2023, LTC Connect recording discusses the top reasons for hospital readmissions and how to recognize early changes in condition to minimize risk for nursing home residents. Additionally, TMF Quality Innovation Network–Quality Improvement Organization specialists review important assessment skills and discuss how early recognition and prevention can potentially decrease emergency department visits and hospital readmissions.

Download the Seven Essential Intervention Categories bundle, developed by the National Transitions of Care Coalition (NTOCC), for assistance in developing and implementing a transitions of care program.

In this recorded webinar on Feb. 29, 2024, TMF QIN-QIO specialists provide a Quality Assurance Performance Improvement (QAPI) refresher with a focus on reducing hospital readmissions. Learn the tried-and-true QAPI principles of collecting and analyzing data, determining goals and objectives, and implementation and monitoring.

The Centers for Medicare & Medicaid Services has created this checklist for patients and caregivers to use to prepare to leave a hospital, nursing home or other health care setting.

Use this medication review tool with the home medications example to help your team develop a quality improvement (QI) plan based on your root case analysis. This document includes sample suggestions and must be modified by the facility team to ensure they reflect their QI work.

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

This CMS QSO-23-16-Hospitals Memo serves as a reminder to hospitals, surveyors and accrediting organizations of the hospital’s requirement to ensure that the health and safety of patients are protected when discharges from hospitals and transfers to post-acute care providers occur. It includes recommendations that hospitals can leverage to improve their discharge policies and procedures to improve and protect patients’ health and safety.

This tool provides sample talking points for nursing homes to communicate quickly and effectively with medical staff about changes in a resident's condition.

Download this document from the National Forum of ESRD Networks that explains how to use the Change in Condition Alert Form in long-term care and dialysis 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.

Use this discharge planning tool to educate residents/patients and/or representatives about ongoing health and medication needs and follow‐up care.

View these tips from the National Consumer Voice for Quality Long-Term Care to help a resident return to his or her community.

Developed by the American Bar Association Commission on Law and Aging, this tool kit contains a variety of self-help worksheets, suggestions and resources.

Developed by the American Bar Association Commission on Law and Aging, this toolkit contains a variety of self-help worksheets, suggestions and resources.

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). In Spanish.