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Tools and Guides


What You Will Find in This Section

Scores of interventions, tools, and best practices to help reduce hospital readmissions are available from HSAG. We have also included links to nationally recognized organizations with care coordination tools and interventions such as BOOST, Project RED, and The Care Transitions Program.

Tools From HSAG

Care Coordination Toolkit

Looking for an overview of tools and interventions to reduce readmissions across care settings—all in one place? Check out our Care Coordination Toolkit that includes samples for hospitals, skilled nursing facilities, and other healthcare providers.

Download and Print Toolkit 

Skilled Nursing Facility Care Coordination Toolkit

This booklet is a compiliation of some of the best HSAG care coordination tools designed specifically for skilled nursing facilities.

Download and Print SNF Toolkit 

Care Coordination Tools From Our States

Where are you located? Find state-specific tools from the HSAG quality innovation network-quality improvement organization (QIN-QIO):

Arizona California  


More Tools Available From National Organizations

Find links to useful care coordination tools from organizations throughout the U.S. 


Administration for Community Living

ADRCs have been working to assist individuals in “critical pathways,” defined as the times or places when people make important decisions about long-term care.

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BOOST - Better Outcomes by Optimizing Safe Transitions

A National initiative led by the Society of Hospital Medicine to improve the care of patients as they transition from hospital to home.

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INTERACT - Interventions to Reduce Acute Care Transfers

A quality improvement program that focuses on the management of acute change in resident condition. It includes clinical and educational tools and strategies for use in every day practice in long-term care facilities.

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Interventions from National Council on Aging (NCOA)

Several tools and intervention resources are available from NCOA, including care transitions, falls, opioids risk, medications, and more.

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RED - Re-Engineered Discharge

The RED intervention is founded on 12 discrete, mutually-reinforcing components and has been proven to reduce rehospitalizations.

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The Care Transitions Program

Targeted for those who are discharged from hospital to home and provides a Transition Coach who focuses on medication self-management, the patient-centered medical record, follow-up appointments, and red flags. Transition Coaches can be incorporated into home health agencies’ model of care.

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