Roadmap of Tools

This guide offers a set of tools to assist your efforts in reducing Medicaid readmissions. The tools are included at the end of this guide as a complete package, but they can also be downloaded online individually. The tools and their description are provided here for at-a-glance reference.

# Tool Description Link
1 Data Analysis Tool Extensively vetted 10-point analysis of data to facilitate a compare and contrast view of readmissions by payer to identify differences between Medicare, Medicaid, commercial, and all-payer rates. Word® (51 KB); PDF (178 KB)
2 Readmission Review Tool Adapted from the well-known STAAR approach, this one-page review guide prompts clinical or quality staff to elicit the patient, caregiver, and provider perspectives about the causes of readmissions. Word (59 KB); PDF (293 KB)
3 Data Analysis Synthesis Tool This template creates a written narrative to describe the results from the quantitative data and readmission interviews. Word (68 KB); PDF (308 KB)
4 Hospital Inventory Tool This tool prompts a comprehensive inventory of readmission reduction activities across departments, service lines, and units within the hospital. Word (50 KB); PDF (233 KB)
5 Cross-Continuum Team Inventory Tool This tool prompts a comprehensive inventory of community-based providers and agencies that provide services helpful in the postdischarge settings. Word (72 KB); PDF (350 KB)
6 Conditions of Participation Checklist This one-page tool, adapted from the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation surveyor guidance, prompts consideration of whether a set of standardized improvements is being provided to all patients, regardless of risk. Word (49 KB); PDF (338 KB)
7 Portfolio Design Tool This tool prompts readmission reduction teams to expand readmission reduction efforts to include action in at least three broad domains: improve standard care for Medicaid patients, collaborate with partners, and provide enhanced services for high-risk patients. Word (107 KB); PDF (419 KB)
8 Readmission Reduction Impact & Financial Analysis Tool This Excel® sheet facilitates modeling of the impact of the strategies on your hospital’s readmission reduction portfolio. It prompts teams to quantify which patients will be served by each strategy, their baseline readmission rate, and the projected readmission reduction. It also helps estimate the avoided utilization (payer cost) due to each strategy, accounts for the investment cost of the intervention (in tools, staff, time), and calculates net "savings" (to payers). Excel® (46 KB); Word (46 KB); PDF (330 KB)
9 Readmission Risk Tool This tool is an educational and awareness-building tool for frontline staff, cross-continuum teams, and quality improvement leadership to quickly review the many factors leading to readmission. It highlights the fact that narrow targeting strategies will miss most readmission risks. Word (45 KB); PDF (247 KB)
10 Whole-Person Assessment This tool provides a checklist to prompt frontline staff to identify and address basic needs. Word (57 KB); PDF (292 KB)
11 Discharge Information Checklist This tool, adapted from the CMS Conditions of Participation, provides a checklist of information that needs to be provided to patients and their receiving providers at the time of transition. Word (45 KB); PDF (281 KB)
12 Forming a Cross-Continuum Team This tool explains the benefits and process of building a cross-continuum team and offers a template for inviting partners to join and a sample workplan for the team. Word (64 KB); PDF (352 KB)
13 Community Resource Guide Tool This tool is modeled on a community resource guide developed by a community-based care management agency. It prompts the hospital readmission reduction team to identify specific contacts at community agencies to facilitate efficient referrals. Word (55  KB); PDF (248 KB)

Return to Contents

Page last reviewed August 2014
Page originally created August 2014