Care Coordination, Interventions - atom Alliance

Interventions

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Providers and communities have used several types of interventions to improve the care coordination and transition of older adults across multiple settings. Many of these contributed to national declines in readmission and admission rates in hospitals across the country.

atom Alliance continues this work with providers in their communities to help select evidence-based interventions associated with known causes of readmission. These include, among other, the following:

Browse our resources below for more information on interventions. We also invite you to join one of many communities using these interventions.

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Featured Resource

CMS Equity Plan
CMS Equity Plan

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433.40 KB | Last Updated: January 26, 2016

Use the tabs to the right to search for specific tools and resources related to this page.

You can also search our comprehensive library of online resources, where you can sort by atom Alliance state, initiative, patient or provider focus or simply type in a keyword for quick access to the tools and resources you need.

In Plain Words
Creating easy-to-read handouts
The Harvard School of Public Health: Health Literacy Studies
Information and tools on developing and assessing innovative materials
CDC Toolkit for Long-Term Care Employers: Seasonal Flu
Provides resources to help long-term care facility, agency or corporation owners and administrators provide access to influenza vaccination for their workforce and to help any employer of workers in long-term care understand the importance of influenza vaccination for their employees
HHS/Healthy People 2020: Social Determinants of Health
Resource offers an overview of Healthy People 2020 objectives, as well as national and local resources and data on key determinants of health.
AHRQ Quality Indicators™ Toolkit for Hospitals
This toolkit is designed to help hospitals understand the Quality Indicators (QIs) from AHRQ and use them to successfully improve quality and patient safety.
Hospital Guide to Reducing Medicaid Readmissions
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.
Health Information in Multiple Languages: MedlinePlus
Offers access to high quality health information for patients in 40 languages; more than 2,500 links to nearly 250 health topics
Better Outcomes for Older Adults through Safe Transitions (BOOST)
BOOSTing Care Transitions implementation toolkit with materials to help optimize the discharge process
Continuity of Care for Suicide Prevention: The Role of Emergency Departments
Paper highlights key steps emergency department (ED) providers can take to establish continuity of care for patients at risk for suicide
Kentucky Department for Aging and Independent Living
The National Consumer Voice
INTERACT 3.0
Agency for Healthcare Research and Quality
Community-Based Care Transition Program
Hospital Compare
Nursing Home Compare
Taking Charge of Your Healthcare
The Conversation Project
AHRQ Health Literacy
The Alliance to Advance Patient Nutrition
The Empowered Patient Coalition
Care Transitions Program
Home Health Quality Improvement (HHQI) Campaign
Center to Advance Palliative Care
National Transitions of Care Coalition
The Dartmouth Atlas of Healthcare
Medline Plus: Health Information in Multiple Languages
Medline Plus: End of Life Issues
Ask Me 3
Why Not the Best: QI Resources for Healthcare Professionals
The Gift Initiative
The Center for Excellence in Assisted Living
Renal Failure Zone Tool
Renal Failure Zone Tool

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287.14 KB | Last Updated: June 20, 2017

Sepsis Zone Tool
Sepsis Zone Tool

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176.14 KB | Last Updated: December 8, 2017

Sepsis Zone Tool Spanish
Sepsis Zone Tool Spanish

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306.22 KB | Last Updated: June 20, 2017

Medication Safety Workgroup Starter Pack (Bundle)
Medication Safety Workgroup Starter Pack (Bundle)

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4.65 MB | Last Updated: February 9, 2016

ADE SMART Goals Worksheet (Interactive)
ADE SMART Goals Worksheet (Interactive)

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566.06 KB | Last Updated: August 20, 2015

PDSA Worksheet for Testing Change (Interactive)
PDSA Worksheet for Testing Change (Interactive)

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318.58 KB | Last Updated: August 21, 2015

ADE Fishbone Diagram (Interactive)
ADE Fishbone Diagram (Interactive)

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345.67 KB | Last Updated: August 20, 2015

2016 Tennessee Care Coordination Communities Directory
2016 Tennessee Care Coordination Communities Directory

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1.61 MB | Last Updated: February 4, 2016

The Care Transitions Project
The Care Transitions Project

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925.14 KB | Last Updated: March 10, 2015

Home Health Interventions Checklist
Home Health Interventions Checklist

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1.03 MB | Last Updated: February 6, 2015

Readmissions Work Sheet
Readmissions Work Sheet

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950.89 KB | Last Updated: February 10, 2015

Communication Needs Assessment
Communication Needs Assessment

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371.06 KB | Last Updated: February 5, 2015

Care Transitions Project Inpatient Facility Interventions
Care Transitions Project Inpatient Facility Interventions

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1.06 MB | Last Updated: February 6, 2015

Rehospitalization Audit
Rehospitalization Audit

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491.07 KB | Last Updated: February 6, 2015

National Quality Strategy Toolkit
National Quality Strategy Toolkit

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1.95 MB | Last Updated: February 5, 2015

National Quality Strategy Lever Fact Sheet
National Quality Strategy Lever Fact Sheet

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304.38 KB | Last Updated: August 21, 2015

National Quality Strategy Fact Sheet
National Quality Strategy Fact Sheet

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343.86 KB | Last Updated: February 5, 2015

Decreasing Readmissions, A Small Hospital
Decreasing Readmissions, A Small Hospital's Story - MS Success Story

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134.00 KB | Last Updated: February 6, 2015

Rapid Estimate of Adult Literacy in Medicine - Short Form (REALM-SF)
Rapid Estimate of Adult Literacy in Medicine - Short Form (REALM-SF)

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25.28 KB | Last Updated: February 6, 2015

Short Assessment of Health Literacy for Spanish Adults (SAHLSA-50)
Short Assessment of Health Literacy for Spanish Adults (SAHLSA-50)

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131.77 KB | Last Updated: February 6, 2015

Universities & Geriatric Education Centers in the South
Universities & Geriatric Education Centers in the South

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1.36 MB | Last Updated: February 6, 2015

Care Coordination Fact Sheet
Care Coordination Fact Sheet

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611.07 KB | Last Updated: February 6, 2015

Nursing Home Staff Interview
Nursing Home Staff Interview

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48.34 KB | Last Updated: February 10, 2015

Figaro: Donna, Nicki & Bill – Caregiver Assistance
AARP’s contest-winning video tells the story of family caregiving through a short film.
AHRQ Patient Safety Videos – Featuring CUSP and TeamSTEPPS
KATS: Kentucky Appalachian Transition Services
See how one community of healthcare providers in Kentucky is focused on reducing hospital readmissions for patients with Medicare and is succeeding in improving patient care.
What Is Palliative Care?
atom Alliance Pinterest Board: Hospital Readmissions & Care Coordination
QIO Program Progress Infographic 2011-2014
QIO Program Progress Infographic 2011-2014

Preview: QIO Program Progress Infographic 2011-2014
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1.68 MB | Last Updated: February 5, 2015

atom Alliance Communities Map
atom Alliance Communities Map

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310.47 KB | Last Updated: October 13, 2014

WalterINFO100x100Infographic: Walter’s Story: A Readmission Timeline

 

CMS Equity Plan
CMS Equity Plan

Preview: CMS Equity Plan
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433.40 KB | Last Updated: January 26, 2016

Logic Models
The QIO Program helps you embrace data in your healthcare setting
Failure Modes & Effects Analysis (FMEA)
The QIO Program shares 5 steps in the Failure Modes and Effects Analysis (FMEA) to anticipate potential problems before they occur
Root Cause Analysis (RCA)
The QIO Program demonstrates how to identify the root cause of a problem using The 5 Whys
An Illustrated Look at QI in Healthcare
QIO Documentary
Learn about the history of the QIO Program, from 1966 through today.
IHI Whiteboard: Model for Improvement, Clip 1
IHI Whiteboard: Model for Improvement, Clip 2
IHI Whiteboard: PDSA Cycles, Part 1
IHI Whiteboard: PDSA Cycles, Part 2
IHI Whiteboard: Cause & Effect Diagrams

Interventions Blog

  • Communication Tool Helps Reduce Hospital Readmissions

    Communication Tool Helps Reduce Hospital Readmissions

    Communication Tool Helps Reduce Hospital Readmissions Effective communication is essential to high-quality healthcare. atom Alliance team members in Indiana are successfully facilitating improvement in transitions of care with the Wabash Valley Care Coalition (WVCC). They are using a communication tool that encourages openness and clarity as a patient’s care is transferred from one member of…
  • An Unlikely Advocate:  A Caregiver Finds atom Alliance After Opioid Overdose

    An Unlikely Advocate: A Caregiver Finds atom Alliance After Opioid Overdose

    by Lindsey Jett, CPht atom Alliance is working with providers and patients throughout the state of Tennessee to increase awareness and education around the opioid epidemic that is facing our state and our nation. We are working with beneficiaries and their families, as well as community healthcare providers, to reduce opioid use in Tennessee.
  • INTERACT Helps Coordinate Care

    INTERACT Helps Coordinate Care

    Hospital readmissions are traumatizing and disruptive to the lives of patients and families. Nationwide, almost a quarter of all patients with Medicare return to the hospital within one month of discharge.

Blog Archive

Care Coordination, Readmissions - atom Alliance

Readmissions

The problem of avoidable readmissions involves multiple providers across multiple settings. See how you can help.

Care Coordination, Adverse Drug Events - atom Alliance

Adverse Drug Events

Adverse drug events are a leading cause of preventable patient harm. Learn what you can do to prevent them.

Care Coordination, Communities - atom Alliance

Communities

Communities across the country are working together to improve care coordination for Medicare beneficiaries in Tennessee. Get involved today.