PFE Provider Change Package Resources

This list of resources provides strategies, interventions and links to help with your patient engagement improvement initiatives. These documents and patient-facing tools will help you and your staff best connect with your patients and help them feel empowered to take charge of their health.

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Care Coordination Discharge

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Implementation Guide for Hospital Admission and Discharge Guides
This implementation guide can assist patient and families in the use of the TMF Hospital Admission and Discharge guides to help improve patient safety and increase patient satisfaction.
Adobe PDF    Date Added: 10/03/2022    Date Last Modified: Mar 8 2023 2:43PM  
Hospital Discharge Discussion Guide for Patients and Families
This guide has a checklist of important items to discuss with your health care team when being discharged from the hospital.
Adobe PDF    Date Added: 04/04/2022    Date Last Modified: Oct 9 2023 4:50PM  
Implementation Guide to Improve Care Transitions
This guide, developed by Better Outcomes for Older Adults through Safe Transitions (Project BOOST) provides resources to optimize the hospital discharge process and mitigate and prevent known complications and errors that occur during care transitions.
Adobe PDF    Date Added: 03/24/2022    Date Last Modified: Mar 24 2022 11:20AM  
Taking Care of Myself: A Guide for When I Leave the Hospital
Using this easy-to-read guide from the Agency for Healthcare Research and Quality with patients during discharge can help them care for themselves when they leave the hospital to track their medication schedules, upcoming medical appointments, and important phone numbers.
Web link    Date Added: 03/24/2022    Date Last Modified: Mar 24 2022 11:45AM  
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  
Readmissions Diagnostic Worksheet
This diagnostic tool from the Institute for Healthcare Improvement, helps hospitals perform an in-depth review of the last five rehospitalizations to identify opportunities for improvement. This includes conducting chart reviews as well as interviews with recently readmitted patients and their family members.
Web link    Date Added: 03/24/2022    Date Last Modified: Mar 24 2022 11:33AM  
Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations
This How-to Guide from the Institute for Healthcare Improvement is designed to support hospital-based teams and their community partners in creating and implementing improved care processes to ensure that patients who have been discharged from the hospital have an ideal transition to the next setting of care (such as a primary care practice, home care or a skilled nursing facility).
Web link    Date Added: 03/24/2022    Date Last Modified: Mar 24 2022 11:38AM  
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  
Patient Discharge Survey (English)
Physicians and nurses at hospitals can use this document to help ensure patients being discharged from the hospital are appropriately led through the discharge process. Hospital staff can also use this survey to help document their own internal patient discharge processes to ensure all of the proper steps were followed.
Adobe PDF    Date Added: 09/08/2021    Date Last Modified: Mar 24 2022 11:47AM  
Find Your Perfect 10 Challenge
Use this tool to identify top 10 patients who are most at risk for an adverse outcome that could result in a hospitalization.
Adobe PDF    Date Added: 03/10/2020    Date Last Modified: Mar 24 2022 11:35AM  
Hospital Follow-up Appointment Postcards
This package includes a postcard in both English and Spanish to give to patients after hospitalization to schedule future appointments. The package also includes instructions for providers to effectively use the postcard.
ZIP archive    Date Added: 11/09/2016    Date Last Modified: Mar 24 2022 11:46AM  
Patient Discharge Survey (Spanish)
Physicians and nurses at hospitals can use this document to help ensure patients being discharged from the hospital are appropriately led through the discharge process. Hospital staff can also use this survey to help document their own internal patient discharge processes to ensure all of the proper steps were followed.
Adobe PDF    Date Added: 02/03/2016    Date Last Modified: Mar 24 2022 11:47AM