Designing and Delivering Whole-Person Transitional Care

Tool Overview

This package of tools accompanies the Designing and Delivering Whole-Person Transitional Care: The Hospital Guide to Reducing Medicaid Readmissions, which offers indepth 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.

Some of the tools are adaptations of best-practice approaches to make them more relevant to the Medicaid population; many tools were newly developed through this project. This introduction offers an overview of the tools available in the package by briefly describing what they are, who should use them, and the time required to use them.

Guide Section Tool Description Staff Time Required
1 Tool 1
Data Analysis (Excel® File, 80 KB)
This spreadsheet facilitates data analysis and interpretation to compare and contrast readmission patterns by payer. Data analyst, business analyst, staff able to query administrative data. 6 hours
1 Tool 2
Readmission Review (Word File, 68 KB)
Adapted from the well-known STAAR approach, this 1-page interview guide prompts clinical or quality staff to elicit a recounting of what happened between discharge and readmission from the patient/caregiver perspective. Quality improvement, nursing, case management staff 5-10 minutes per interview. Consider starting with 5 interviews; many teams later review ALL readmissions when the patient is readmitted.
2 Tool 3
Hospital Inventory Tool (Word File, 67 KB)
This tool prompts a comprehensive inventory of readmission reduction activity and related organizational and operational assets across departments, service lines, and units within the hospital. Day-to-day champion, in collaboration with readmission reduction team. 4 hours. Take no more than 2 weeks (2 meetings) to complete.
2 Tool 4
Community Inventory (Word File, 73 KB)
This tool prompts an inventory of postacute and community-based providers, agencies, and plans that can offer posthospital services. Readmission reduction champion as a component of strategic planning; delegated to day-to-day lead or social worker to conduct in collaboration with community partners. 4-5 hours, delegated across multiple staff
3 Tool 5
Portfolio Design (PowerPoint File, 354 KB)
This PowerPoint deck includes examples of readmission reduction portfolios that can be modified to develop the data-informed, multifaceted portfolio of readmission reduction efforts in your hospital. Readmission reduction strategic leadership team 3 to 4 hours
3 Tool 6
Operational Dashboard (PowerPoint File, 369.5 KB)
This PowerPoint deck provides an example of an operational dashboard to track measures of monthly discharge volume, monthly implementation measures, and monthly outcomes (readmission rates). Readmission champion and day-to-day leader. 1 hour to review; 2 hours monthly to populate.
3 Tool 7
Portfolio Presentation (PowerPoint File, 558 KB)
This PowerPoint deck summarizes the findings of the quantitative and qualitative data review, hospital and community inventory, aim, target population, and data-informed strategy to reduce readmissions. Readmission reduction champion and/or day-to-day leader. 2 hours
4 Tool 8
Conditions of Participation (Word File, 65.3 KB)
This 1-page handout offers an overview of the transitional care practices as outlined by the guidance and proposed changes to the CMS Conditions of Participation (COPs). It can be used as a handout, in educational sessions, and as a guide to the work of your readmission reduction team. Readmission reduction champion (in strategic planning); day-to-day leader (education and improvement work). 30 minutes to review and consider circulating or discussing at next readmissions team meeting.
4 Tool 9
Whole-Person Transitional Care Planning (Word File, 73 KB)
This tool gives discharge planners a set of prompts to identify readmission risks and to take steps to ensure those risks are addressed in the transitional care (discharge) plan. Day-to-day readmission reduction champion to test, adapt, and incorporate into existing workflow with frontline staff. Incorporate into regular discharge planning assessment and referrals.
4 Tool 10
Discharge Process Checklist (Word File, 76.75 KB)
This tool, adapted from the CMS COPs, provides a checklist of discharge elements that CMS states should be provided to all Medicare and Medicaid patients. This tool can be used to update existing processes and identify whether new processes and practices need to be implemented. Readmission champion and day-to-day leader. 1 hour to review and 1-3 hours to discuss with hospital colleagues the extent to which various elements are reliably delivered.
5 Tool 11
Community Resource Guide (Word File, 87 KB)
This is a two-part tool: a community resource guide and a 1-page “quick reference” version. The purpose is to stimulate the development of an extended set of contacts at community agencies, specifically agencies and providers who can meet the posthospital and ongoing clinical, behavioral, and social service needs of the Medicaid population or other high-risk patients. Delegate to a social worker to complete with community providers and agencies. 12 hours initially. Take no more than 1 month to draft. Update periodically (e.g., once or twice a year).
5 Tool 12
Cross-Continuum Collaboration (Word File, 73.3 KB)
This tool helps teams develop specific effective and timely linkages to services with cross-continuum clinical, behavioral, and social service providers. Readmission day-to-day champion. 2 hours to review and apply recommendations.
6 Tool 13
ED Care Plan Examples (Word File, 71.25 KB)
This tool provides an emergency department care plan template and examples of ED care plans. Hospitals can use this template, adapt the template, or draw inspiration from the examples to develop their own template to suit their specific needs and preferences. Champion of efforts to reduce frequent utilization. Target 30 minutes per patient to develop a care plan. Note that the first 10 patients may require significantly more time as the team learns what information to incorporate. Weekly or biweekly meetings are recommended to review and discuss care plans.

Return to Contents

Page last reviewed October 2016
Page originally created August 2014
Internet Citation: Tool Overview. Content last reviewed October 2016. Agency for Healthcare Research and Quality, Rockville, MD.
Back To Top