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
Super Utilizers
Only show items containing the term:
SEARCH
SORT BY
Alphabetical
Most Recently Added
Oldest First
Search Resource Center
Searching...
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
HANDOUT: Going Beyond SDOH to Reduce Readmissions
TRANSCRIPT: Going Beyond SDOH to Reduce Readmissions
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
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
HANDOUT: Care Transitions Intervention: Coaching Patients to Successfully Transition from Hospital to Home
TRANSCRIPT: Care Transitions Intervention: Coaching Patients to Successfully Transition from Hospital to Home
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
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
HANDOUT: A Process Improvement Discovery Tool - Readmissions (QIN-QIO)
TRANSCRIPT: A Process Improvement Discovery Tool - Readmissions (QIN-QIO)
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
HANDOUT: Skilled Nursing Facility Care Coordination Toolkit
TRANSCRIPT: Skilled Nursing Facility Care Coordination Toolkit
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
HANDOUT: Creating Pathways to Stability
TRANSCRIPT: Creating Pathways to Stability
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
HANDOUT: The New EMS Value Proposition
TRANSCRIPT: The New EMS Value Proposition
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
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
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
HANDOUT: Emergency Department Visits Related to Mental Health Disorders Among Adults, by Race and Hispanic Ethnicity: United States, 2018–2020
TRANSCRIPT: Emergency Department Visits Related to Mental Health Disorders Among Adults, by Race and Hispanic Ethnicity: United States, 2018–2020
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
HANDOUT: Super Utilizer Management Intervention List
TRANSCRIPT: Super Utilizer Management Intervention List
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
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
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
HANDOUT: Video: Develop a Process to Manage Super Utilizers
TRANSCRIPT: Video: Develop a Process to Manage Super Utilizers
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
HANDOUT: Where for Care Plan
TRANSCRIPT: Where for Care Plan
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
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
HANDOUT: 8 Tips for High-Quality Hand-Offs
TRANSCRIPT: 8 Tips for High-Quality Hand-Offs
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
HANDOUT: Targeting High Utilizers
TRANSCRIPT: Targeting High Utilizers
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
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
HANDOUT: Managing Care for Super Utilizers
TRANSCRIPT: Managing Care for Super Utilizers
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
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
HANDOUT: My Emergency Plan (English)
TRANSCRIPT: My Emergency Plan (English)
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
HANDOUT: My Emergency Plan (Spanish)
TRANSCRIPT: My Emergency Plan (Spanish)