Readmission Reduction/Transitional Care Toolkit

Many readmissions are avoidable and can lead to unnecessary high costs and directly impact your success in meeting quality targets and potential for shared savings. Targeting readmissions will help identify opportunities to ensure patients are getting the right care, at the right time, and in the most cost effective/appropriate health care setting.  
The Transitional Care Checklist is designed to provide practices with a quick reference checklist for the key elements of Transitional Care.  
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.  
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.  
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.  
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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