Care Coordination, Readmissions - atom Alliance

Readmissions

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One in five adults aged 65 and older is ataischarged from the hospital only to be readmitted again. The issue involves multiple providers across several settings. We must understand not only what is going on within hospital walls, but also what is taking place after patients leave.

Main causes of readmissions include

  • Poor information transfer or communication between providers
  • Decreased patient and family involvement
  • Underutilized support services to assist with activities of daily living
  • Multiple chronic health conditions

atom Alliance is bringing together state-wide communities to create powerful collaborations of change. These communities are united in the goals to

  • reduce hospital readmission and admission rates in the Medicare program by 20 percent by 2019 and
  • increase the patient’s time spent at home after discharge by 10 percent.

Join a community today to get started.

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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.

Guide to Preventing Readmissions among Racially and Ethnically Diverse Medicare Beneficiaries
IOM Roundtable on Health Literacy
The mission of the Roundtable is to inform, inspire, and activate a wide variety of stakeholders to support the development, implementation, and sharing of evidence-based health literacy practices and policies.
IOM Roundtable on Health Literacy: Ten Attributes of Health Literate Health Care Organizations
Discussion paper highlights findings to determine ten attributes of health-literate healthcare organizations
In Plain Words
Creating easy-to-read handouts
HRSA’s Unified Health Communication (UHC): Addressing Health Literacy, Cultural Competency, and Limited English Proficiency
Online health literacy course offered by the Department of Health and Human Services’ Health Resources and Services Administration
The Harvard School of Public Health: Health Literacy Studies
Information and tools on developing and assessing innovative materials
National Network of Libraries of Medicine, National Library of Medicine: Health Literacy
Health literacy resources
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.
National Plan to Address Alzheimer’s Disease: 2014 Update
Activities outlined in the plan vary in scope and impact to include: (1) immediate actions that the Federal Government will take; (2) actions toward the goals that can be initiated by the Federal Government or its public and private partners in the near term; and (3) longer-range activities that will require numerous actions to achieve.
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.
Next Step in Care
Provides easy to use guides to help caregivers and healthcare providers work closely to plan and implement smooth transitions for chronically or seriously ill patients
Medicaring
Aims to build a healthcare system that can find patients who are living with serious and complex illness, tailor services to their priorities, and plan and pay providers in a way that encourages quality care at a price that communities and families can bear
Eldercare Locator
A public service of the U.S. Administration on Aging connecting you to services for older adults and their families
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
Transitional Care Model
Multidisciplinary, comprehensive in-hospital planning and home follow-up
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
Advance Care Planning, Preferences for Care at the End of Life
Research from AHRQ that helps physicians and ohealth care professionals guide patient decision making for care at the end of life
Readmissions Penalties by State (Year 3)—Kaiser Health News
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
Project RED
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
Speak Up Initiative
IHI Hospital to Home: Excellence in Transitions
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

Preview: 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: June 20, 2017

Sepsis Zone Tool Spanish
Sepsis Zone Tool Spanish

Preview: 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)

Preview: 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)

Preview: 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)

Preview: 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

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

Poster: Clinical Pharmacist Impact on Heart Failure Guideline Compliance and Hospitalization Rates in the Long-Term Care Setting
Poster: Clinical Pharmacist Impact on Heart Failure Guideline Compliance and Hospitalization Rates in the Long-Term Care Setting
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)

Preview: 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

West Tennessee Senior Resource Guide
West Tennessee Senior Resource Guide

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789.35 KB | Last Updated: February 6, 2015

Readmission Root Cause Analysis Tool - Skilled Nursing Facility
Readmission Root Cause Analysis Tool - Skilled Nursing Facility

Preview: Readmission Root Cause Analysis Tool - Skilled Nursing Facility
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291.73 KB | Last Updated: February 6, 2015

Discharge Criteria
Discharge Criteria

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146.67 KB | Last Updated: February 5, 2015

Help Decrease Avoidable Rehospitalizations
Help Decrease Avoidable Rehospitalizations

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5.51 MB | Last Updated: February 6, 2015

Depression Zone Tool
Depression Zone Tool

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285.09 KB | Last Updated: August 21, 2015

Asthma Zone Tool
Asthma Zone Tool

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296.89 KB | Last Updated: February 6, 2015

10 Reasons a Physicians Should Consider a Hospice
10 Reasons a Physicians Should Consider a Hospice

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2.68 MB | Last Updated: February 23, 2015

Chart Review for Unplanned Transfers
Chart Review for Unplanned Transfers

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231.18 KB | Last Updated: February 6, 2015

Heart Disease Zone Tool
Heart Disease Zone Tool

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298.18 KB | Last Updated: February 6, 2015

Home Health Interview Form
Home Health Interview Form

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34.80 KB | Last Updated: February 6, 2015

Hospice Change Package
Hospice Change Package

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3.20 MB | Last Updated: February 6, 2015

IHI How to Guide: Improving Transitions
IHI How to Guide: Improving Transitions

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1.06 MB | Last Updated: February 6, 2015

Physical Therapy Zone Tool
Physical Therapy Zone Tool

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303.17 KB | Last Updated: February 6, 2015

Post-ACH/ROC Transfer Tool
Post-ACH/ROC Transfer Tool

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327.53 KB | Last Updated: February 10, 2015

Process of Care Tool for Home Health Agencies
Process of Care Tool for Home Health Agencies

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312.04 KB | Last Updated: February 6, 2015

Rehospitalization Audit
Rehospitalization Audit

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491.07 KB | Last Updated: February 6, 2015

Rehospitalization Clinical Review Tool
Rehospitalization Clinical Review Tool

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315.82 KB | Last Updated: February 6, 2015

Respiratory Disease Zone Tool
Respiratory Disease Zone Tool

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290.91 KB | Last Updated: February 6, 2015

Chart Audit Tool for Hospitals
Chart Audit Tool for Hospitals

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254.69 KB | Last Updated: February 10, 2015

Chart Audit Tool for Nursing Homes
Chart Audit Tool for Nursing Homes

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190.51 KB | Last Updated: February 6, 2015

Skilled Nursing Facility and Rehabilitation Change Package
Skilled Nursing Facility and Rehabilitation Change Package

Preview: Skilled Nursing Facility and Rehabilitation Change Package
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4.71 MB | 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

Physician Practice Assessment Form
Physician Practice Assessment Form

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22.32 KB | Last Updated: February 26, 2015

Change Package: Physician Office
Change Package: Physician Office

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29.93 KB | Last Updated: February 5, 2015

Figaro: Donna, Nicki & Bill – Caregiver Assistance
AARP’s contest-winning video tells the story of family caregiving through a short film.
Honoring Choices Wisconsin
Wisconsin Medical Society promotes the benefits of improving processes for advance care planning across the state in healthcare settings and in the community
CDC Vital Signs: Stop the Spread of Antibiotic Resistance
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

 

 

 

 

 

 
TN_Interactive_Readmission_MapMap: Interactive Map Shows Tennessee Readmissions Savings Per County

Understanding the Path to Readmissions Infographic
Understanding the Path to Readmissions Infographic

Preview: Understanding the Path to Readmissions Infographic
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1.93 MB | Last Updated: February 6, 2015

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
INTERACT 3.0
Video: Domestic Lean Goddess PDSA
Creating a Strong Team
Creating a Strong Team

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291.77 KB | Last Updated: February 6, 2015

Interactive PDSA Worksheet
Interactive PDSA Worksheet

Preview: Interactive PDSA Worksheet
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223.14 KB | Last Updated: February 6, 2015

Using PDSA for Quality Improvement
Using PDSA for Quality Improvement

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54.30 KB | Last Updated: February 6, 2015

Readmissions Blog

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