Category: Readmissions / Care Transitions

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.

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

National Association of Community Health Centers

This resource contains the 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.

Quality Improvement (QI) and Care Coordination; Implementing the CDC Guideline for Prescribing Opioids for Chronic Pain

Centers for Disease Control (CDC)

Intended to help healthcare systems integrate the Guideline and associated quality improvement (QI) measures into their clinical practice. Offers primary care providers, practices, and healthcare systems a framework for managing patients who are on long-term opioid therapy.

Designing and Delivering Whole-Person Transitional Care; The Hospital Guide to Reducing Medicaid Readmissions

Agency for Healthcare Research and Quality (AHRQ)

Reducing readmissions is a national priority for payers, providers, and policymakers seeking to improve health care and lower costs. Readmissions are a significant issue among patients with Medicaid. The Agency for Healthcare Research and Quality (AHRQ) commissioned this guide to identify ways evidence-based strategies to reduce readmissions can be adapted or expanded to better address the transitional care needs of the adult Medicaid population. The guide has been field tested by individual hospitals and groups of hospital quality improvement collaboratives. Based on a series of coaching and feedback calls with hospitals, the second release of this guide has been updated to provide updated tools and clearer guidance on who should use the tools and what to do with the output of the tools. It also offers new tools that can be used in the day-to-day working environment of hospital-based teams and cross-setting partnerships.

Hospital Guide to Reducing Medicaid Readmissions Toolbox

Agency for Healthcare Research and Quality (AHRQ)

Offers in depth information about the unique factors driving Medicaid readmissions and a step-by-step process for designing a locally relevant portfolio of strategies to reduce Medicaid readmissions. Toolkit includes patient and family interview process.

Strategy 4: Care Transitions From Hospital to Home: IDEAL Discharge Planning

Agency for Healthcare Research and Quality (AHRQ)

Discharge from hospital to home requires the successful transfer of information from clinicians to the patient and family to reduce adverse events and prevent readmissions. Engaging patients and families in the discharge planning process helps make this transition in care safe and effective. Strategy 4: Care Transitions From Hospital to Home: IDEAL Discharge Planning highlights the key elements of engaging the patient and family in discharge planning.

Taking Care of Myself: A Guide for When I Leave the Hospital

Agency for Healthcare Research and Quality (AHRQ)

A guide that providers can use to give patients the information they need to help them care for themselves when they leave the hospital. Using this easy-to-read guide 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.

Re-Engineered Discharge (RED) Toolkit

Agency for Healthcare Research and Quality (AHRQ)

A variety of forces are pushing hospitals to improve their discharge processes to reduce readmissions. Researchers at the Boston University Medical Center (BUMC) developed and tested the Re-Engineered Discharge (RED). Research showed that the RED was effective at reducing readmissions and posthospital emergency department (ED) visits. The Agency for Healthcare Research and Quality contracted with BUMC to develop this toolkit to assist hospitals, particularly those that serve diverse populations, to replicate the RED.