Tag: Toolkit/Tools

Patient Family Advisory Councils Toolkit

Colorado Hospital Association

With the shift in the health care landscape from volume to value, more hospitals are engaging patients in their everyday hospital activities. Like any profession, learning from the consumer can provide great insight on how to provide better service. Integrating patient and family advisory councils (PFACs) within the hospital setting is an excellent approach to learn from patients and increase the quality of care delivered in a hospital. The toolkit underscores PFAC support with quality and safety, patient satisfaction, patient outcomes and market share.

The Michigan Opioid Safety Score (MOSS): A Patient Safety and Nurse Empowerment Tool

Journal of PeriAnesthesia Nursing

The Michigan Opioid Safety Score (MOSS) was developed to incorporate patient risk, respiratory rate, and sedation into one bedside score that could be used to improve patient safety during inpatient opioid therapy. Scoring is based on a summation of risk data with objective bedside measures of over-sedation trumping a patient’s subjective reports of pain.

Opioid Overdose Prevention TOOLKIT & Opioid Use Disorder Facts

Substance Abuse and Mental Health Services Administration (SAMHSA)

This toolkit offers strategies to health care providers, communities, and local governments for developing practices and policies to help prevent opioid-related overdoses and deaths. Access reports for community members, prescribers, patients and families, and those recovering from opioid overdose.

  • Scope of the Problem
  • Strategies to Prevent Overdose Deaths
  • Resources for Communities

GRACE Team Care Model: Geriatric Resources for Assessment and Care of Elders (GRACE)

Agency Healthcare Research and Quality (AHRQ) & Indiana University School of Medicine’s Center for Aging Research

Designed as a promising solution to the health and health care challenges faced by low-income seniors with multiple chronic conditions, researchers at Indiana University developed the GRACE Team Care model  to assist primary care physicians (PCPs) working with low-income seniors to optimize health and functional status, decrease excess usage of health care services, and prevent unnecessary long-term nursing home placement.

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.

COVID-19 Resources on Vulnerable Populations

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.

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.