Search Resource Center
 

Advance Care Planning for African Americans
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.
Web link    Date Added: 08/03/2023    Date Last Modified: Aug 3 2023 12:32PM  
AHRQ/Re-Engineered Discharge (RED): Post-Discharge Follow-Up Phone Call Tool
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.
Web link    Date Added: 12/06/2023    Date Last Modified: Dec 6 2023 8:42AM  
Best Practices Pocket Cards
These Best Practices Pocket Cards can be printed and laminated for education, training and reminders for staff in a variety of topics.
Web link    Date Added: 05/01/2023    Date Last Modified: May 1 2023 10:17AM  
Brown Bag Medicine Reviews
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.
Web link    Date Added: 03/07/2024    Date Last Modified: Mar 7 2024 9:50AM  
Call for Help Action Plan - Partnership for Community Health
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).
Web link    Date Added: 09/02/2022    Date Last Modified: Dec 14 2022 9:11AM  
Caring Conversations Workbook and Materials
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.
Web link    Date Added: 08/03/2023    Date Last Modified: Aug 3 2023 11:18AM  
Claims-Based Measure Tip Sheet: Successful Discharge to the Community from Post-Acute Care
This claims-based measure tip sheet provides an overview of the measure, including questions to ask, monitoring ideas and resource links.
Adobe PDF    Date Added: 07/06/2022    Date Last Modified: Jul 6 2022 10:14AM  
Community Resources and Safety Tips for Going Home
Use this tool to identify community-specific resources to give to discharging residents/patients.
Microsoft Word    Date Added: 08/27/2020    Date Last Modified: Aug 27 2020 4:00PM  
COVID-19 Status Communication Form
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.
Adobe PDF    Date Added: 11/21/2021    Date Last Modified: Nov 19 2021 12:17PM  
Emergency Department Care Transitions Assessment
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.
Adobe PDF    Date Added: 07/20/2023    Date Last Modified: Jul 20 2023 2:44PM  
Emergency Department Visit Toolkit For Long-term Care Facilities
This toolkit provides your team with actionable steps to decrease the number of hospital transfers of short stay residents.
Adobe PDF    Date Added: 05/06/2024    Date Last Modified: May 6 2024 1:58PM  
ePrognosis
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.
Web link    Date Added: 04/25/2024    Date Last Modified: Apr 25 2024 12:56PM  
Feb. 16 LTC Connect: Adverse Drug Events
This presentation is from the Feb. 16, 2023, LTC Connect webinar, "Adverse Drug Events."
Adobe PDF    Date Added: 02/09/2023    Date Last Modified: Feb 9 2023 4:06PM  
Five Wishes
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.
Web link    Date Added: 08/03/2023    Date Last Modified: Aug 3 2023 12:32PM  
INTERACT® Tools Library – Pathway INTERACT®
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.
Web link    Date Added: 10/18/2022    Date Last Modified: Oct 18 2022 7:20PM  
June 15 LTC Connect: Preventing ED Visits
This presentation is from the June 15, 2023, LTC Connect webinar, "Preventing ED Visits."
Adobe PDF    Date Added: 06/14/2023    Date Last Modified: Jun 14 2023 12:57PM  
Loving Conversations Video Series
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.
Web link    Date Added: 08/03/2023    Date Last Modified: Aug 3 2023 12:37PM  
LTC Connect: Adverse Drug Events
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.
Video    Date Added: 02/22/2023    Date Last Modified: Feb 22 2023 8:45AM  
LTC Connect: Fall Reduction and ADLs – Helping to Prevent ED Visits
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.
Video    Date Added: 08/24/2023    Date Last Modified: Dec 20 2023 10:30AM  
LTC Connect: Preventing ED Visits
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.
Video    Date Added: 06/20/2023    Date Last Modified: Jun 21 2023 11:58AM  
LTC Connect: Readmissions – Early Recognition of Change
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.
Video    Date Added: 05/22/2023    Date Last Modified: Jun 13 2023 4:11PM  
NTOCC Care Transition Bundle: Seven Essential Intervention Categories
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.
Adobe PDF    Date Added: 02/09/2024    Date Last Modified: Jan 25 2024 2:55PM  
Nursing Home Connect: QAPI Focus – Reducing Hospital Readmissions
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.
WebEx    Date Added: 03/04/2024    Date Last Modified: Mar 4 2024 11:10AM  
Planning for Your Discharge
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.
Web link    Date Added: 04/23/2020    Date Last Modified: Apr 23 2020 9:45PM  
Quality Improvement Plan: Medication Review Process - Home Medications
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.
Adobe PDF    Date Added: 12/20/2022    Date Last Modified: Dec 20 2022 12:30PM  
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  
Requirements for Hospital Discharges to Post-Acute Care Providers
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.
Web link    Date Added: 08/03/2023    Date Last Modified: Aug 3 2023 12:39PM  
SBAR for Resident Change in Condition
This tool provides sample talking points for nursing homes to communicate quickly and effectively with medical staff about changes in a resident's condition.
Adobe PDF    Date Added: 05/10/2023    Date Last Modified: Jun 13 2023 3:36PM  
Sharing Highly Effective Practice
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.
Adobe PDF    Date Added: 11/21/2021    Date Last Modified: Nov 19 2021 12:13PM  
Skilled Nursing Facility (SNF) Care Transitions Assessment
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.
Adobe PDF    Date Added: 01/23/2023    Date Last Modified: Jan 30 2023 9:13AM  
Successful Discharge to the Community - Clinical Discharge Planning Checklist
Use this discharge planning tool to educate residents/patients and/or representatives about ongoing health and medication needs and follow‐up care.
Microsoft Word    Date Added: 08/27/2020    Date Last Modified: Aug 27 2020 4:57PM  
Tips for People Moving from a Nursing Home Back into the Community
View these tips from the National Consumer Voice for Quality Long-Term Care to help a resident return to his or her community.
Adobe PDF    Date Added: 04/23/2020    Date Last Modified: Apr 23 2020 10:07PM  
Tool Kit for Health Care Advance Planning
Developed by the American Bar Association Commission on Law and Aging, this tool kit contains a variety of self-help worksheets, suggestions and resources.
Web link    Date Added: 02/28/2024    Date Last Modified: Feb 28 2024 10:30AM  
Toolkit for Health Care Advance Planning
Developed by the American Bar Association Commission on Law and Aging, this toolkit contains a variety of self-help worksheets, suggestions and resources.
Adobe PDF    Date Added: 08/03/2023    Date Last Modified: Aug 3 2023 12:25PM  
Call for Help Action Plan - Partnership for Community Health (Spanish for Puerto Rico)
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.
Adobe PDF    Date Added: 12/14/2022    Date Last Modified: Dec 14 2022 9:19AM