Create an Account
Login
SEARCH
Home
Networks
Nursing Homes/Skilled Nursing Facilities
Partnership for Community Health
Hospital Quality Improvement Initiative
Patient and Family Engagement Network
Quality Improvement Initiative
Events
Resources
Resource Library
Online Forums
Success Stories
Podcasts
Help with Your Account
Manage Email Notifications
Update Your Profile
About Us
Contact Us
Mission and Governance
Coronavirus
COVID-19 Resources
Upcoming COVID-19 Events
Vaccinations and Building Immunity
Climate Change
Create an Account
Login
SEARCH
Home
Networks
Nursing Homes/Skilled Nursing Facilities
Partnership for Community Health
Hospital Quality Improvement Initiative
Patient and Family Engagement Network
Quality Improvement Initiative
Events
Resources
Resource Library
Online Forums
Success Stories
Podcasts
Help with Your Account
Manage Email Notifications
Update Your Profile
About Us
Contact Us
Mission and Governance
Coronavirus
COVID-19 Resources
Upcoming COVID-19 Events
Vaccinations and Building Immunity
Climate Change
Home
/
Networks
/
Partnership for Community Health
/
Change Packages and Interventions
Change Packages and Interventions
Click on a category to filter the change packages.
Opioid Misuse Change Package and
Interventions
Care Transitions Change Packages and Interventions
Improve Patient Safety and Prevent Adverse Drug Events in the Community
Improve the Quality of Care Transitions
Emergency Room Use
Hospital Readmissions
Super-Utilizer Management
Chronic Disease Change Packages and Interventions
Cardiovascular Health
Chronic Kidney Disease
Diabetes
Diabetes Prevention Program
Hemoglobin A1c
High Blood Pressure
Tobacco Cessation
Infection Control Change Package
Hospital Readmissions
Only show items containing the term:
SEARCH
SORT BY
Alphabetical
Most Recently Added
Oldest First
Search Resource Center
Searching...
How to Reduce Chronic Obstructive Pulmonary Disease Readmissions
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.
Video
Date Added:
11/08/2023
Date Last Modified:
Nov 29 2023 11:26AM
HANDOUT: How to Reduce Chronic Obstructive Pulmonary Disease Readmissions
TRANSCRIPT: How to Reduce Chronic Obstructive Pulmonary Disease Readmissions
Podcast Series: Buprenorphine Initiation in the Emergency Department – Why, When, and How?
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.
Podcast
Date Added:
10/20/2023
Date Last Modified:
Oct 20 2023 7:04PM
HANDOUT: Podcast Series: Buprenorphine Initiation in the Emergency Department – Why, When, and How?
TRANSCRIPT: Podcast Series: Buprenorphine Initiation in the Emergency Department – Why, When, and How?
Improving Hospital Transfers: A Step Toward Equitable, Patient-Centered Acute Care
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.
Web link
Date Added:
10/20/2023
Date Last Modified:
Oct 20 2023 1:39PM
HANDOUT: Improving Hospital Transfers: A Step Toward Equitable, Patient-Centered Acute Care
TRANSCRIPT: Improving Hospital Transfers: A Step Toward Equitable, Patient-Centered Acute Care
The hospital readmissions reduction program: a population-based study
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.
Web link
Date Added:
10/13/2023
Date Last Modified:
Oct 16 2023 6:14AM
HANDOUT: The hospital readmissions reduction program: a population-based study
TRANSCRIPT: The hospital readmissions reduction program: a population-based study
Health Equity/Disparities—Health Area Deprivation Index, Session Two
This webinar recording, organized by Health Services Advisory Group (HSAG), introduces tools to address health disparities and social determinants of health that impact readmissions.
WebEx
Date Added:
08/30/2023
Date Last Modified:
Aug 30 2023 9:59AM
HANDOUT: Health Equity/Disparities—Health Area Deprivation Index, Session Two
TRANSCRIPT: Health Equity/Disparities—Health Area Deprivation Index, Session Two
The Role of Health Equity in Care Coordination
This presentation, organized by Health Services Advisory Group (HSAG), discusses how a facility can identify the contributing factors that impact health equity and readmissions.
Web link
Date Added:
08/30/2023
Date Last Modified:
Aug 30 2023 9:37AM
HANDOUT: The Role of Health Equity in Care Coordination
TRANSCRIPT: The Role of Health Equity in Care Coordination
Quality Improvement for Heart Failure and Cardiac Rehabilitation
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.
Video
Date Added:
08/07/2023
Date Last Modified:
Aug 7 2023 2:05PM
HANDOUT: Quality Improvement for Heart Failure and Cardiac Rehabilitation
TRANSCRIPT: Quality Improvement for Heart Failure and Cardiac Rehabilitation
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
HANDOUT: Emergency Department Care Transitions Assessment
TRANSCRIPT: Emergency Department Care Transitions Assessment
New Issue Brief Addresses Diagnostic Safety During Transitions of Care
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.
Adobe PDF
Date Added:
06/16/2023
Date Last Modified:
Jun 16 2023 12:54PM
HANDOUT: New Issue Brief Addresses Diagnostic Safety During Transitions of Care
TRANSCRIPT: New Issue Brief Addresses Diagnostic Safety During Transitions of Care
5 ways patient engagement can improve outcomes
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.
Web link
Date Added:
06/12/2023
Date Last Modified:
Jun 12 2023 12:03PM
HANDOUT: 5 ways patient engagement can improve outcomes
TRANSCRIPT: 5 ways patient engagement can improve outcomes
Chronic Care Management (CCM) Questions and Answers
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.
Video
Date Added:
06/07/2023
Date Last Modified:
Jun 7 2023 12:00PM
HANDOUT: Chronic Care Management (CCM) Questions and Answers
TRANSCRIPT: Chronic Care Management (CCM) Questions and Answers
Health Disparities in Heart Failure Admissions Cost Over $60M
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.
Web link
Date Added:
05/23/2023
Date Last Modified:
May 23 2023 9:33AM
HANDOUT: Health Disparities in Heart Failure Admissions Cost Over $60M
TRANSCRIPT: Health Disparities in Heart Failure Admissions Cost Over $60M
How does stress from everyday life impact heart health?
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.
Web link
Date Added:
05/23/2023
Date Last Modified:
May 23 2023 9:43AM
HANDOUT: How does stress from everyday life impact heart health?
TRANSCRIPT: How does stress from everyday life impact heart health?
Multiple-admission Patient (MAP) Program Framework
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.
Adobe PDF
Date Added:
05/18/2023
Date Last Modified:
May 19 2023 5:14PM
HANDOUT: Multiple-admission Patient (MAP) Program Framework
TRANSCRIPT: Multiple-admission Patient (MAP) Program Framework
What works in medication reconciliation: an on-treatment and site analysis of the MARQUIS2 study
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.
Unknown item type
Date Added:
05/15/2023
Date Last Modified:
May 15 2023 3:39PM
HANDOUT: What works in medication reconciliation: an on-treatment and site analysis of the MARQUIS2 study
TRANSCRIPT: What works in medication reconciliation: an on-treatment and site analysis of the MARQUIS2 study
My Care Transition Plan
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.
Adobe PDF
Date Added:
05/15/2023
Date Last Modified:
May 15 2023 1:10PM
HANDOUT: My Care Transition Plan
TRANSCRIPT: My Care Transition Plan
Investing in education for better health, reduced readmissions
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.
Web link
Date Added:
04/14/2023
Date Last Modified:
May 2 2023 9:54AM
HANDOUT: Investing in education for better health, reduced readmissions
TRANSCRIPT: Investing in education for better health, reduced readmissions
Where for Care
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.
Web link
Date Added:
04/14/2023
Date Last Modified:
Apr 14 2023 8:22AM
HANDOUT: Where for Care
TRANSCRIPT: Where for Care
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, 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.
Video
Date Added:
02/15/2023
Date Last Modified:
Oct 30 2023 4:50PM
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
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:
Aug 22 2023 11:15PM
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)