Society Hospital Medicine (SHM)
Evidence-based bundled intervention for hospitals to use to identify patients at high risk for readmission and guide the discharge plan based on identified needs assessed upon hospital admission; provides the patient a Transitional Record to guide them during the post-acute period.
Cost associated with implementation.
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.
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.
Central Massachusetts Community coalition in Partnership with Healthcentric Advisors
Decision Guide for Referrals to Community Based Organizations – A Tool for patients or a loved one.
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.
Substance Abuse and Mental Health Services Administration (SAMHSA)
This guide equips clinicians with information for treating chronic pain in adults living with a history of substance use. The guide discusses chronic pain management, including treatment with opioids. It also includes information about substance use assessments and referrals. Available at no cost from SAMSHA.
The Centers for Medicare & Medicaid Services Office of Minority Health (CMS OMH)
The Centers for Medicare & Medicaid Services Office of Minority Health (CMS OMH) has compiled Federal resources on the 2019 Novel Coronavirus (COVID-19) to assist our partners who work with those most vulnerable—such as older adults, those with underlying medical conditions, racial and ethnic minorities, rural communities, and people with disabilities.
IHI – Institute for Healthcare Improvement
This guide is intended to help health care staff and leaders have trust-building conversations about the COVID-19 vaccine, both at work and at home. Exploring people’s feelings about the vaccine through respectful, trust-building interactions over time offers the potential to increase the uptake of vaccinations. The guide helps health care staff and leaders begin to quickly engage in effective conversations about COVID-19 vaccination, enabling learning in practice and resolving issues that arise from such conversations. The focus is on having rich conversations to listen and learn about reasons and feelings for not getting vaccinated — and then seeking to have a dialogue about questions and concerns so that people can consider COVID-19 vaccination.
Centers for Disease Control (CDC), National Healthcare Safety Network (NHSN)
NHSN subject matter experts have created training videos for 2021 NHSN updates. Recorded presentations cover the following topics:
Rural Health Information Hub (RHIhub)
Curated selection of resources and information for hospitals and inpatient settings to address challenges and maintain operations during healthcare surges.
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).
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.
