Exploring Sepsis Strategies-Part 2: Care Coordination & Preventing Sepsis-Related Readmissions

This material was prepared by Telligen in partnership with IPRO HQIC, the Hospital Quality Improvement Contractor, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS)

This is the second session in a two-part series Webinar on Sepsis from September 30 11 PT 12 MT 1 CT 2 EDT. View the recording, as well as the questions and answers presentation slide deck.

This session focuses on preventing sepsis-related harm and avoidable readmissions using effective care coordination and hand-off strategies to the next level of care provider.

Patient Safety Analysis Quick Reference Guides

Centers for Disease Control and Prevention

These quick reference guides were created to help you understand, modify, and interpret your data using the NHSN application’s various analysis output (report) options for the NHSN Patient Safety Component. These guides serve as companions to the “Introduction to NHSN Analysis” training slide set.

National Healthcare Safety Network (NHSN)Patient Safety Analysis Resource

Centers for Disease Control and Prevention

The NHSN application provides various options that allow NHSN users to analyze their surveillance data. The resources listed on the link above are intended to help you use the analysis tool, and interpret data analyzed from the Patient Safety Component of NHSN.

Preadmissions Planning Checklist (Spanish)

This material was prepared by American Institutes for Research (AIR). It is redistributed by IPRO HQIC, a Hospital Quality Improvement Contractor, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS).

HOW TO PREPARE FOR A SAFE HOSPITAL STAY”

This resource is a planning checklist for Spanish speaking patients to use prior to admission to the hospital, while admitted, and before they leave the hospital

Preadmissions Planning Checklist(English)


This material was prepared by American Institutes for Research (AIR). It is redistributed by IPRO HQIC, a Hospital Quality Improvement Contractor, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS).

HOW TO PREPARE FOR A SAFE HOSPITAL STAY”

This resource is a planning checklist for patients to use prior to admission to the hospital, while admitted, and before they leave the hospital

All-Cause Harm Resource

This resource explains what All-Cause Harm is, why it is important and then dives into each of the processes it takes to prevent All-Cause Harm. Eight priority focus areas for the Hospital Quality Improvement Contract (HQIC) are illuminated and strategies to monitor compliance are provided.

All-Cause Harm Resource, Recording and Slides from the IPRO HQIC All-Cause Harm “launch” on March 29th, 2021.

Project RED (Re-Engineered Discharge)

Project RED is supported by grants from the Agency for Healthcare Research and Quality (AHRQ) and the National Institutes of Health (NIH)-National Heart, Lung and Blood Institute (NHBLI), the Blue Cross Blue Shield Foundation, and the Patient-Centered Outcomes Research Institute.

Hospital based care transition model that coordinates the patient’s discharge plan throughout the hospitalization and then provides a post-acute discharge guide and follow-up telephone calls.

Project Re-Engineered Discharge is a research group at Boston University Medical Center that develops and tests strategies to improve the hospital discharge process in a way that promotes patient safety and reduces re-hospitalization rates. The RED (re-engineered discharge) intervention is founded on 12 discrete, mutually reinforcing components and has been proven to reduce rehospitalizations and yields high rates of patient satisfaction.  Virtual patient advocates are currently being tested in conjunction with the RED. In addition, Project RED has started to implement the re-engineered discharge at other hospitals serving diverse patient populations. We are also looking at the transitional needs from inpatient to outpatient care of specific populations (i.e., those with depressive symptoms). Finally, we are about to start a patient-centered project to create a tool that hospitals can use to discover factors (i.e., medical legal, social, etc.) in patients’ readmissions.

IHI STAAR Root Cause Analysis Tool

Institute for Healthcare Improvement (IHI)

Chart Reviews of Patients Who Were Readmitted: This Root Cause Analysis (RCA) tool is one of those that we recommend for hospitals.

Conduct chart reviews of the last five readmitted patients. Reviewers should be physicians or nurses from the hospital and community settings. Reviewers should not look to assign blame, but rather to discover opportunities to improve the care of patients.

Interventions to Reduce Acute Care Transfers (INTERACT): Interventions to Reduce Acute Care Transfers

Pathway Health: Project supported by the Centers for Medicare and Medicaid Services (CMS)

INTERACT (Interventions to Reduce Acute Care Transfers) is a quality improvement program that focuses on the management of acute change in resident condition. It includes clinical and educational tools and strategies for use in everyday practice in long-term care centers. INTERACT is designed to improve the early identification, assessment, documentation, and communication about changes in the status of residents. The goal of INTERACT is to improve care and reduce the frequency of potentially avoidable transfers to the acute hospital.

Website requires login, tools are free.

Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE)

National Association of Community Health Centers

Set of national core measures as well as a set of optional measures for community priorities. It was informed by research, the experience of existing social risk assessments, and stakeholder engagement. It aligns with national initiatives prioritizing social determinants (e.g., Healthy People 2020), measures proposed under the next stage of Meaningful Use, clinical coding under ICD-10, and health centers’ Uniform Data System (UDS).

Complex Care at NYC H+H: Operational Guide to Identify, Understand, and Treat High-Need Patients

NYC Health & Hospitals

This guide features open-source implementation tools which could be customized, and used to support other health system’s efforts to identify, understand, and treat patients with complex needs.
This guide provides step-by-step guidance on:
1) Risk scoring and stratification: using data and analytics to identify patients with complex needs;
2) Segmentation: combining analytics with clinical insight to understand patients with complex needs; and
3) Targeting: tailoring care models to fit needs and behaviors of patients with complex needs.