Change Packages and Interventions

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Super Utilizers

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Emergency Department Visits Related to Mental Health Disorders Among Adults, by Race and Hispanic Ethnicity: United States, 2018–2020
This report, from the National Center for Health Statistics, shows that rates of Emergency Department (ED) visits for any mental health disorder were highest among non-Hispanic Black adults (96.8) compared with non-Hispanic White (53.4) and Hispanic (36.0) adults. Adults made an average of 774,508 mental health-related ED visits per year from 2018 to 2020, accounting for 12.3% of all ED visits made by adults.
Adobe PDF    Date Added: 03/29/2023    Date Last Modified: Mar 29 2023 12:23PM  
Super Utilizer Management Intervention List
Download this list of interventions you and your hospital staff can use to help to decrease hospital use for Medicare beneficiaries who are identified as super utilizers.
Adobe PDF    Date Added: 03/07/2023    Date Last Modified: Mar 7 2023 12:26PM  
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  
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  
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  
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  
Video: Develop a Process to Manage Super Utilizers
The purpose of this video is to highlight health care quality improvement interventions hospitals can implement to help manage super utilizers in the health care system.
Video    Date Added: 06/20/2022    Date Last Modified: Jun 20 2022 1:46PM  
Where for Care Plan
This one-page document the Where for Care campaign developed helps guide the reader through developing a care plan before an actual medical emergency takes place.
Adobe PDF    Date Added: 04/14/2022    Date Last Modified: Apr 14 2022 4:02PM  
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  
8 Tips for High-Quality Hand-Offs
Download this infographic to view what The Joint Commission considers are the eight tips for high-quality patient hand offs.
Adobe PDF    Date Added: 04/14/2022    Date Last Modified: Apr 14 2022 4:05PM  
Targeting High Utilizers
Download this PDF of a PowerPoint presentation developed by the Denver Health Alliance that explores different care models to address super utilizers’ needs.
Adobe PDF    Date Added: 04/14/2022    Date Last Modified: Apr 14 2022 8:02AM  
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  
Managing Care for Super Utilizers
Download this list of case examples from the New York State Department of Health to learn how to manage super utilizers in various care settings and/or with other service providers and nonprofit organizations.
Adobe PDF    Date Added: 04/12/2022    Date Last Modified: Apr 12 2022 6:26PM  
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  
My Emergency Plan (English)
Internists/primary care physicians and nurses: Provide this document to your patients, which includes more information to help them ascertain when to call your office for help or when to go to the emergency room for a range of conditions, including shortness of breath, heart failure, complications with diabetes and more. Patients: Use this document to help determine when to call your physician for help or when to go to the emergency department for assistance.
Adobe PDF    Date Added: 02/03/2015    Date Last Modified: Apr 14 2022 4:01PM  
My Emergency Plan (Spanish)
Internists/primary care physicians and nurses: Provide this document to your patients, which includes more information to help them ascertain when to call your office for help or when to go to the emergency room for a range of conditions, including shortness of breath, heart failure, complications with diabetes and more. Patients: Use this document to help determine when to call your physician for help or when to go to the emergency department for assistance.
Adobe PDF    Date Added: 02/03/2015    Date Last Modified: Apr 14 2022 4:02PM