This study examined whether socio-demographic and -economic factors influence 30-day readmissions for conditions such as chronic obstructive pulmonary disease, pneumonia, acute myocardial infarction and heart failure.

Download this field guide that lists various approaches used by Quality Improvement Organizations to help improve transitions of care within different communities across the United States.

This Jan. 2, 2024, article from The Dallas Observer highlights the success of the RIGHT Care Unit, which consists of an interdisciplinary team of first responders and health care professionals who respond to 911 calls from individuals experiencing behavioral health crises across the Dallas metro area.

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.

Listen and learn from nationally recognized experts in four, 15-minute podcasts about the importance and effectiveness of starting buprenorphine treatment for opioid use disorder in emergency departments.

This article discusses ways to improve patient transfers from one facility to another. Effective transfers helps ensure that all patients have access to quality care.

Hospital readmission rates for people with conditions targeted by the CMS Hospital Readmission Reduction Program (HRRP) have not changed, according to results of a study published in BMC Public Health. In this article, researchers describe their data collection methods, summarize current conditions and offer strategies for reducing hospital readmissions.

This webinar recording, organized by Health Services Advisory Group (HSAG), introduces tools to address health disparities and social determinants of health that impact readmissions.

This presentation, organized by Health Services Advisory Group (HSAG), discusses how a facility can identify the contributing factors that impact health equity and readmissions.

In this recorded, one-hour webinar, Jessica Wauson, from the American Heart Association, shares evidence-based guidelines for treating heart failure. Also featured: a review of the patient assessments and education tools that patients can use to successfully manage their condition.

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.

In the health care industry, the error risk is high when patients are transferred from one entity to another, such as from a hospital to a short-term rehabilitation center. This new issue brief discusses the potential for errors during all transitions in care. The brief identifies how diagnostic errors can be made and provides strategies to reduce these errors.

Actively engaging patients in their care prior to discharge can ensure patients get the right care at the right time. This article discusses how educating patients about the benefits and programs available to them can help them manage their care needs.

This March 14, 2023 recorded webinar provides information about the new guidelines on chronic care management (CCM). The presesntation is given by Ellen Berra, Wisconsin Physician Services Government Health Administrators, a Medicare Administrative Contractor, MAC. Berra and TMF's Ardis Reed, MPH, RD, LD, CDCES then answer participants' questions in this one-hour event.

This article examines results of a study published in Health Affairs. One finding, according to researchers: health inequity costs the Medicare program more than $60 million on preventable heart failure hospital admissions.

Stress has been linked to heart health complications, such as atrial fibrillation, coronary heart disease and sudden cardiac death. This article shares news from a team of UC Davis Health scientists who will study the impact of stress from everyday life on heart health in underserved communities.

This document, provided by the Eastern US Quality Improvement Collaborative (EQIC), is a part of EQIC's MAP program. The MAP program is designed to identify patients who are frequently admitted to the hospital, provide patient-specific interventions to address contributing factors and engage community-based organizations to reduce preventable readmissions.

Documenting medication history, before a patient is discharged from a hospital emergency department (ED), and then reconciling medications upon discharge, is an effective way to reduce medication discrepancies, according to recent study.

Patients with caregivers and/or care partners are asked to complete this form, which lists patients' concerns on care needs at home. Hospital staff will work with patients and caregivers to address concerns on the list.

When you or a loved one gets sick or injured, and your health care provider's office is closed, you might immediately head for the emergency room. That may not be the best place for your care, however. Take a few minutes to review this resource and make a decision about where to go for care based on your symptoms.

This article describes the successful quality improvement and community education efforts at Community Hospital, McCook, NE. Community Hospital is a critical access facility that provides advanced care to more than 30,000 people throughout southwest Nebraska and northwest Kansas.

This abstract describes the results of a study that examined the effectiveness of interventions designed to safeguard patients when transitioning from the hospital to home.

This article discusses how a person's wellbeing is a predictor for 30-day readmission rates. Patients with the highest wellbeing are less than half as likely to be readmitted than patients with inconsistent or poor wellbeing.

In this video, Kimberly Jungkind, a health care quality improvement specialist with the TMF Quality Innovation Network-Quality Improvement Organization, discusses how to reduce readmissions for patients with congestive heart failure (CHF). Jungkind shares resources that support patients with CHF to better manage their condition, and she offers innovative ideas for helping patients with CHF buy and cook foods that are heart healthy.

On Jan. 25, 2023, TMF QIN-QIO specialists discussed strategies for reducing readmissions and increasing patient and family engagement. The attendees also learned about care transitions, the TMF Patient and Family Engagement Network and the Partnership for Community Health Network.

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.

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.

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.

This form can be used to help patients and their families talk with health care providers about being admitted to a new health care setting such as a long-term care facility, in-patient rehabilitation, skilled nursing facility or a long-term acute care facility.

Watch this video to learn how to implement lasting solutions to help your facility reduce avoidable readmissions.

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.

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.

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.

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.

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.

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.

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.

Download this one-page list of interventions you and your hospital staff can use to help reduce 30-day 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.

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.

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.

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.

A checklist for hospitals to review current interventions, or initiate new ones, to aid readmissions reduction in your facility.

The Care Transitions Program provides insights and tools for how to improve quality and manage risk during care hand-overs.

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.

Trauma-informed care acknowledges that understanding a patient’s life experiences is key to potentially improving engagement and outcomes while lowering unnecessary utilization.

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.

Use this form for patients being readmitted to psychiatric care to determine the factors leading to readmission.

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.

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.

This form can be used to help patients and their families talk with health care providers about being admitted to a new health care setting such as a long-term care facility, in-patient rehabilitation, skilled nursing facility or a long-term acute care facility.

This guide has a checklist of important items to discuss with your health care team when being discharged from a long-term care facility, in-patient rehabilitation, skilled nursing facility, or a long-term acute care facility.