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Change Packages and Interventions
Change Packages and Interventions
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Opioid Misuse Change Package and
Interventions
Care Transitions Change Packages and Interventions
Improve the Quality of Care Transitions
Emergency Room Use
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Super-Utilizer Management
Chronic Disease Change Packages and Interventions
Cardiovascular Health
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Diabetes Prevention Program
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Infection Control Change Package
Hospital Readmissions
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The effect of transitions intervention to ensure patient safety and satisfaction when transferred from hospital to home health care -- a systematic review.
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.
Web link
Date Added:
03/17/2023
Date Last Modified:
Mar 17 2023 9:15AM
HANDOUT: The effect of transitions intervention to ensure patient safety and satisfaction when transferred from hospital to home health care -- a systematic review.
TRANSCRIPT: The effect of transitions intervention to ensure patient safety and satisfaction when transferred from hospital to home health care -- a systematic review.
Patient Wellbeing Closely Linked to 30-Day Readmission Rates
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.
Web link
Date Added:
03/08/2023
Date Last Modified:
Mar 8 2023 8:36AM
HANDOUT: Patient Wellbeing Closely Linked to 30-Day Readmission Rates
TRANSCRIPT: Patient Wellbeing Closely Linked to 30-Day Readmission Rates
How to Reduce Congestive Heart Failure Readmissions
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.
Video
Date Added:
02/16/2023
Date Last Modified:
Feb 16 2023 9:00AM
HANDOUT: How to Reduce Congestive Heart Failure Readmissions
TRANSCRIPT: How to Reduce Congestive Heart Failure Readmissions
Jan. 25, Patient and Family Engagement (PFE) Strategies for Reducing Readmissions: Best-Practice Interventions, Tools and Resources
On Jan. 25, TMF QIN-QIO specialists discuss strategies for reducing readmissions and increasing patient and family engagement. Also addressed: care transitions, the TMF Patient and Family Engagement Network and the Partnership for Community Health Network.
Video
Date Added:
02/15/2023
Date Last Modified:
Feb 15 2023 10:25AM
HANDOUT: Jan. 25, Patient and Family Engagement (PFE) Strategies for Reducing Readmissions: Best-Practice Interventions, Tools and Resources
TRANSCRIPT: Jan. 25, Patient and Family Engagement (PFE) Strategies for Reducing Readmissions: Best-Practice Interventions, Tools and Resources
Acute Care Provider 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:
01/24/2023
Date Last Modified:
Jan 24 2023 9:53AM
HANDOUT: Acute Care Provider Care Transitions Assessment
TRANSCRIPT: Acute Care Provider Care Transitions Assessment
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:
01/23/2023
Date Last Modified:
Jan 30 2023 9:12AM
HANDOUT: Emergency Department Care Transitions Assessment
TRANSCRIPT: Emergency Department Care Transitions Assessment
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
HANDOUT: Skilled Nursing Facility (SNF) Care Transitions Assessment
TRANSCRIPT: Skilled Nursing Facility (SNF) Care Transitions Assessment
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
HANDOUT: Improve the Quality of Care Transitions Change Package
TRANSCRIPT: Improve the Quality of Care Transitions Change Package
Admissions Guide for Partnership for Community Health members
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.
Adobe PDF
Date Added:
11/04/2022
Date Last Modified:
Feb 28 2023 8:12AM
HANDOUT: Admissions Guide for Partnership for Community Health members
TRANSCRIPT: Admissions Guide for Partnership for Community Health members
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
HANDOUT: Video: Reducing Avoidable Readmissions
TRANSCRIPT: Video: Reducing Avoidable Readmissions
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
HANDOUT: Hospital Score Calculator
TRANSCRIPT: Hospital Score Calculator
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
HANDOUT: Pathway Health – INTERACT
TRANSCRIPT: Pathway Health – INTERACT
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
HANDOUT: Tool 2, Readmissions Review Tool
TRANSCRIPT: Tool 2, Readmissions Review Tool
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
HANDOUT: Virginia Commonwealth University Health System: Social Needs Assessment
TRANSCRIPT: Virginia Commonwealth University Health System: Social Needs Assessment
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
HANDOUT: The EveryONE Project – Social Determinants of Health Guide to Social Needs Screening
TRANSCRIPT: The EveryONE Project – Social Determinants of Health Guide to Social Needs Screening
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
HANDOUT: Social Needs Patient Action Plan
TRANSCRIPT: Social Needs Patient Action Plan
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
HANDOUT: Upstream Risks Screening Tool and Guide
TRANSCRIPT: Upstream Risks Screening Tool and Guide
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
HANDOUT: Hospital Readmission Reduction Intervention List
TRANSCRIPT: Hospital Readmission Reduction Intervention List
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
HANDOUT: Modified LACE Tool
TRANSCRIPT: Modified LACE Tool
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
HANDOUT: Re-Engineered Discharge (RED) Toolkit
TRANSCRIPT: Re-Engineered Discharge (RED) Toolkit
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
HANDOUT: Your Discharge Planning Checklist
TRANSCRIPT: Your Discharge Planning Checklist
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
HANDOUT: CMS Hospital Discharge Planning Worksheet
TRANSCRIPT: CMS Hospital Discharge Planning Worksheet
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
HANDOUT: Hospital Readmissions Tracer Tool
TRANSCRIPT: Hospital Readmissions Tracer Tool
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
HANDOUT: Preventable Readmissions Top 10 Checklist
TRANSCRIPT: Preventable Readmissions Top 10 Checklist
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
HANDOUT: The Care Transitions Program
TRANSCRIPT: The Care Transitions Program
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
HANDOUT: 7-Day Readmission Audit Tool
TRANSCRIPT: 7-Day Readmission Audit Tool
10 Key ingredients for Trauma-informed care
Trauma-informed care acknowledges that understanding a patient’s life experiences is key to potentially improving engagement and outcomes while lowering unnecessary utilization.
Adobe PDF
Date Added:
01/24/2020
Date Last Modified:
Jan 24 2023 10:00AM
HANDOUT: 10 Key ingredients for Trauma-informed care
TRANSCRIPT: 10 Key ingredients for Trauma-informed care
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
HANDOUT: 7-Day Readmission Checklist and Audit Tool Instructions
TRANSCRIPT: 7-Day Readmission Checklist and Audit Tool Instructions
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
HANDOUT: Patient Interview Form: 30-Day Psychiatric Readmissions
TRANSCRIPT: Patient Interview Form: 30-Day Psychiatric Readmissions
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
HANDOUT: Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation
TRANSCRIPT: Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation
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
HANDOUT: Re-Engineered Discharge (RED) Toolkit
TRANSCRIPT: Re-Engineered Discharge (RED) Toolkit
Admissions Guide for Partnership for Community Health members (Spanish)
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.
Adobe PDF
Date Added:
02/28/2023
Date Last Modified:
Feb 28 2023 8:28AM
HANDOUT: Admissions Guide for Partnership for Community Health members (Spanish)
TRANSCRIPT: Admissions Guide for Partnership for Community Health members (Spanish)
Discharge Guide for Partnership for Community Health members (Spanish)
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.
Adobe PDF
Date Added:
02/28/2023
Date Last Modified:
Feb 28 2023 8:31AM
HANDOUT: Discharge Guide for Partnership for Community Health members (Spanish)
TRANSCRIPT: Discharge Guide for Partnership for Community Health members (Spanish)