Readmission Reduction/Transitional Care Toolkit

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Readmissions are one of the drivers of high health care costs in the United States, and many are avoidable. This toolkit offers valuable tools and resources to support Care Transitions and reduce the risk of readmission for Medicare and non-Medicare patients. All tools are customizable to meet the needs of your practice.  
Before exploring this Readmission Reduction Toolkit, we recommend viewing this recorded webinar which offers strategies to support transitions of care and reduce the risk of readmission for your patients.  
The Transitional Care Checklist is designed to provide practices with a quick reference checklist for the key elements of Transitional Care.  
Supports the Medicare Annual Visit by allowing for pre-visit, visit and post-visit planning.  
The Annual Visit Patient Tracker is designed to support practices with some of the best ways to manage their Medicare patients.  
The Transitional Care Protocol is a useful checklist for practices to ensure they address each critical step of the post-discharge follow-up office visit.  
Designed to assist practices with the scripting of the post-discharge phone call to connect patients to their PCP, this script is modifiable to meet each practice’s individual workflow needs.  
This template enables practices to organize the contact information for all of a patient’s providers into one convenient document so patients can easily access their healthcare support team.  
The Medication Planner is a tool designed to highlight some of the key elements when reviewing medications with patients.  
These commonly used screening tools for Behavioral Health are available for practices that would like to implement tools to detect the leading Behavioral Health diagnoses that can negatively impact readmission rates.  
The STEADI tool, translated as Stopping Elderly Accidents, Deaths & Injuries, was created by the CDC to help practices identify patients that are at risk of falls and hospital readmissions due to causes unrelated to the original hospital admission.  
This critical tool helps patients, Care Coordinators and providers identify barriers to a patient’s care and recovery so they can be addressed (and removed) as soon as possible.  
This tool solidifies the responsibility the provider, patient and caretaker have to work as a team to ensure the patient avoids a hospital readmission.  
Health Alert Cards  
These cards help patients recognize when a serious medical emergency is imminent. Cards for Acute Myocardial Infarction, Pneumonia, and Congestive Heart Failure are provided.  
Health Alert Card-Acute Myocardial Infarction
Health Alert Card-Pneumonia
Health Alert Card-Congestive Heart Failure
 
A workflow that demonstrates the organization of patient care activities to achieve safe and effective patient care.  
Care planning is an approach to care customized to an individual patient’s needs. Care plans are called for when a patient can benefit from personalized instruction and feedback to help manage a health condition or multiple conditions.  
This template is patient-centered for the patient and patient’s care team to support their transitional care post-discharge.  
This template helps practices organize local and national resources in a handy one-pager so it can be shared with patients during their post-discharge office visit.  
This modifiable sample agreement allows hospitals, practices and skilled nursing facilities to communicate the role each organization will play in sharing information to ensure healthy patient handoffs.  
Palliative care/Advanced Illness Care is medical care designed to improve the quality of life for patients with serious illness.  
Care Management is the coordination and planning of care in order to reduce fragmented and unnecessary use of services, prevent avoidable ER use, admissions, readmissions, and promote independence and self-care.  
These workflows help to reduce hospital readmissions, potentially avoidable ER visits, ambulatory sensitive admissions, and to increase generic dispensing rates to maximize shared savings. 
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