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Using behavioral health practices to reduce psychiatric readmissions: Session 2, Transition to Home
Watch this one-hour recorded webinar to learn about identifying and developing partnerships with community-based organizations. Subject matter experts also discussed how to use data to support managing behavioral health conditions across the care continuum and to develop workflows between organizations to ensure appropriate handoffs.
Video    Date Added: 05/22/2024    Date Last Modified: May 24 2024 6:20AM  
Using behavioral health practices to reduce psychiatric readmissions Session 1, The Hospital Discharge
Watch this one-hour recorded webinar to learn about the common barriers that hospitals encounter with patients with mental health conditions. Subject matter experts also discussed interventions for patients at risk for readmission and the strategies that one hospital used to better manage psychiatric readmissions.
Video    Date Added: 05/14/2024    Date Last Modified: May 20 2024 2:55PM  
COPD Toolkit
Download this fact sheet from the TMF Quality Innovation Network to help patients better manage their Chronic Obstructive Pulmonary Disease (COPD).
Adobe PDF    Date Added: 02/02/2024    Date Last Modified: Feb 2 2024 12:34PM  
Going Beyond SDOH to Reduce Readmissions
This article examines recent research about how new technologies, such as artificial intelligence, can be used in a post-discharge patient engagement program. New technologies could address factors beyond social determinants of health (SDOH) and address emotional, behavioral and other barriers to recovery.
Adobe PDF    Date Added: 08/30/2023    Date Last Modified: Aug 30 2023 9:20AM  
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  
Care Transitions Intervention: Coaching Patients to Successfully Transition from Hospital to Home
Read about the 30-day Care Transitions Intervention® (CTI®), which was created with reducing the number of preventable readmissions among Medicare beneficiaries.
Web link    Date Added: 07/24/2023    Date Last Modified: Jul 24 2023 1:29PM  
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  
A Process Improvement Discovery Tool - Readmissions (QIN-QIO)
The Process Improvement Discovery Tool helps Partnership for Community Health member hospitals provide safer patient care. The tool helps health care providers identify process improvement opportunities for reducing readmissions.
Adobe PDF    Date Added: 07/18/2023    Date Last Modified: Jul 18 2023 9:13AM  
Skilled Nursing Facility Care Coordination Toolkit
Research shows that more than 20% of Medicare beneficiaries discharged from a hospital to a skilled nursing facility will return to a hospital within 30 days, costing Medicare more than $4 billion per year. These returns are often due to potentially preventable conditions, such as dehydration, infections, medication errors, and unaddressed social needs. This toolkit provides an overview of care coordination best practices to avert hospital readmissions.
Adobe PDF    Date Added: 07/10/2023    Date Last Modified: Jul 10 2023 1:11PM  
Creating Pathways to Stability
This webinar recording describes a hospital and community health center collaboration that works to address the underlying needs of the patients who are most likely to become frequent visitors to hospital emergency rooms. The goal is to improve their quality of life outcomes and reduce readmissions while supporting substance users in central Houston.
Video    Date Added: 07/10/2023    Date Last Modified: Aug 10 2023 4:36PM  
The New EMS Value Proposition
This May 16, 2023, recorded webinar features Matt Zavadsky, the chief transformation officer at MedStar Mobile Healthcare. Zavadsky, also an emergency medical technician, explains what it means to be a "mobile health care provider," which transforms the traditional role of emergency medical services into more than merely a conveyance method. If you have questions or want a copy of the handout, please contact us at communityhealth@tmf.org.
Video    Date Added: 05/24/2023    Date Last Modified: Jun 27 2023 1:41PM  
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  
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  
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, 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  
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: Aug 22 2023 11:15PM  
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