The Aging Network and Care Transitions: Preparing your Organization Toolkit

This toolkit was developed for health care provider organizations that are ready to prepare their organization for a role in care transitions programs. Many of the patients served by the Aging Network are considered high-risk for multiple hospital readmissions and the accompanying health complications. The goal of the National Aging Network is to ensure that patients and their caregivers understand post-discharge instructions for medication and self care, recognize symptoms that may indicate complications requiring immediate attention, and that they make and keep their follow-up appointments with their primary care physicians. The toolkit is available as group of several web pages and requires a web browser to view it.

• Details
• Related Solutions

• Category: Operational/Financial Efficiency

• Source: Administration on Aging (AOA)

• Setting of Care: Ambulatory/Ancillary setting, Hospital inpatient

• Quality Improvement Goals And Mechanisms: Avoidable Hospitalizations

• Patient Population: Vulnerable populations

• Tags: Readmissions, Care Transitions, Aging

	Health Care Leader Action Guide to Reduce Avoidable Readmissions Reducing avoidable hospital readmissions is an opportunity to improve quality and reduce costs in the health care system. This guide, developed by the Health Research and Educational Trust, is designed to serve as a starting point for hospital leaders to assess, prioritize, implement, and monitor strategies to reduce avoidable readmissions. The guide is available as a PDF and requires Adobe Reader.
	The Aging Network and Care Transitions: Preparing your Organization Toolkit This toolkit was developed for health care provider organizations that are ready to prepare their organization for a role in care transitions programs. Many of the patients served by the Aging Network are considered high-risk for multiple hospital readmissions and the accompanying health complications.
	Identifying Potentially Preventable Readmissions Hospital readmission rates may result from actions taken or omitted during the initial hospital stay and are an indication of the quality of patient care. Preventable readmission (PPR) methods are outlined in this paper and it addresses methods to identify potentially preventable hospital readmissions using computerized discharge abstract data. These methods will help to increase the quality of patient care; and could also compliment pay-for-performance incentives. The paper is available as a PDF and requires Adobe Reader to view it.
	Continuity of Care, Transfer Project Strategies & Tools to Improve the Transfer Process The purpose of the Continuity of Care Transfer Project is to improve the quality, safety and stability of care transitions of patients and residents to and from hospital emergency departments, nursing units and long-term care communities. All healthcare facilities will benefit by improving the efficiency and effectiveness of transfers, which will reduce readmissions. The strategies and tools include developed recommended best practices, model forms and guidelines. The toolkit is available as a PDF and requires Adobe Reader to view it.
	Implementation Guide for Readmissions The Partnership for Patients purpose is to reduce readmissions by developing a more cohesive plan of care that is clearly communicated to the patient and family upon discharge. The main factors are medication reconciliation, communication handoff, post-discharge access and post-discharge plan of care. Their Evidence-Based Practice Guidelines based on the “Project Re-Engineered Discharge” intervention program. The toolkit is available as a PDF and requires Adobe Reader to view it.