Change Packages and Interventions

Download our change packages for COVID-19, Flu and Pneumonia

Click on a category to filter the change packages.

Hospital Readmissions

Only show items containing the term:
 
SORT BY
Search Resource Center
 

Hospital Readmission Reduction Intervention List
Download this one-page list of interventions you and your hospital staff can use to help reduce 30-day hospital readmissions.
Adobe PDF    Date Added: 04/13/2022    Date Last Modified: Aug 9 2022 1:55PM  
The EveryONE Project – Social Determinants of Health Guide to Social Needs Screening
The American Academy of Family Physicians created this handout to help care teams understand social determinants of health and how to develop a team-based care approach to identify specific patient needs and how to address those needs.
Adobe PDF    Date Added: 04/14/2022    Date Last Modified: Apr 14 2022 4:30PM  
Social Needs Patient Action Plan
The American Academy of Family Physicians created this two-page fillable PDF document to allow a care team member to work directly with a patient to document the social determinants that may influence their health needs.
Adobe PDF    Date Added: 04/14/2022    Date Last Modified: Apr 14 2022 4:30PM  
Upstream Risks Screening Tool and Guide
The AAMC created this five-page checklist for care team members to use to help prompt patients to provide more information about themselves, which can help identify areas of need that have historically not been addressed in the traditional clinical setting.
Adobe PDF    Date Added: 04/14/2022    Date Last Modified: Apr 14 2022 4:29PM  
Video: Reducing Avoidable Readmissions
Watch this video to learn how to implement lasting solutions to help your facility reduce avoidable readmissions.
Video    Date Added: 06/20/2022    Date Last Modified: Jun 20 2022 10:15AM  
Patient Interview Form: 30-Day Psychiatric Readmissions
Use this form for patients being readmitted to psychiatric care to determine the factors leading to readmission.
Adobe PDF    Date Added: 01/11/2018    Date Last Modified: Apr 14 2022 4:27PM  
7-Day Readmission Checklist and Audit Tool Instructions
This one-page audit tool prompts clinical or quality staff members to review a list of factors commonly attributed to preventable hospital readmissions. The review can help you understand the kinds of barriers patients, families, and providers face during preparation of discharge to the post-hospital transitional care period and the circumstances leading patients to return to the hospital.
Adobe PDF    Date Added: 08/08/2018    Date Last Modified: May 10 2022 2:53PM  
Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation
The Medications at Transitions and Clinical Handoffs (MATCH) toolkit was developed to help facilities improve their medication reconciliation process. This toolkit provides a step-by-step guide to help health care providers ensure patients are properly educated about the medications they have been prescribed to help avoid medication errors and patient harm.
Web link    Date Added: 05/12/2015    Date Last Modified: Apr 14 2022 4:17PM  
Re-Engineered Discharge (RED) Toolkit
The Agency for Healthcare Research and Quality, in coordination with Boston University Medical Center, has developed an online Re-Engineered Discharge (RED) tool kit. RED has been shown to be effective in reducing readmissions and post-hospital emergency department visits.
Web link    Date Added: 03/22/2013    Date Last Modified: Apr 14 2022 4:15PM  
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  
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  
7-Day Readmission Audit Tool
This Microsoft Excel spreadsheet audit tool prompts clinical or quality staff members to review a list of factors commonly attributed to preventable hospital readmissions. The review can help you understand the kinds of barriers patients, families, and providers face during preparation of discharge to the post-hospital transitional care period and the circumstances leading patients to return to the hospital.
Microsoft Excel    Date Added: 09/08/2020    Date Last Modified: Apr 14 2022 4:26PM  
Your Discharge Planning Checklist
This easy-to-use checklist from the Centers for Medicare & Medicaid Services (CMS) is for patients and their caregivers preparing to leave a hospital, nursing home or other care setting.
Adobe PDF    Date Added: 03/24/2022    Date Last Modified: Apr 14 2022 4:17PM  
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  
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  
Re-Engineered Discharge (RED) Toolkit
Researchers at the Boston University Medical Center developed and tested a set of activities and materials for improving the hospital discharge process, which they called the Re-Engineered Discharge (RED). Research showed that the RED was effective at reducing readmissions and post-discharge emergency visits. RED consists of a set of 12 mutually reinforcing actions; outlined in this toolkit.
Adobe PDF    Date Added: 03/24/2022    Date Last Modified: Apr 14 2022 4:15PM  
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  
Hospital Score Calculator
Calculate by QxMD developed this online calculator to help hospitals identify patients who are more likely to be readmitted. Once hospitals identify those patients, hospital discharge staff can give those patients needed instructions when discharged from the hospital to another care setting or home to help lessen the likelihood that they will be readmitted to the hospital.
Web link    Date Added: 04/20/2022    Date Last Modified: Apr 20 2022 8:28AM  
Pathway Health – INTERACT
Scroll down on this webpage to find free resources you and your hospital staff can use to develop or strengthen your care transitions plans and processes.
Web link    Date Added: 04/20/2022    Date Last Modified: Apr 20 2022 8:36AM  
Tool 2, Readmissions Review Tool
Agency for Healthcare Research and Quality developed this document for health care staff to use to interview patients about their care experience and why they were readmitted.
Microsoft Word    Date Added: 04/20/2022    Date Last Modified: Apr 20 2022 8:40AM  
Virginia Commonwealth University Health System: Social Needs Assessment
The Center for Health Care Strategies, Inc. developed this multi-page questionnaire to help health care providers determine where their patients need assistance with a variety of medical and social health care needs.
Adobe PDF    Date Added: 04/20/2022    Date Last Modified: Apr 20 2022 8:46AM