The Network, in accordance with the Centers for Medicare & Medicaid Services (CMS), is working to improve care transitions and reduce ESRD-related hospitalizations, readmissions, and emergency department visits. The tools and resources on this page are intended to assist dialysis facility staff, patients, family, and caregivers to reduce avoidable hospital use.
- SMART Goals Resource
- Hospital Action Plan Guidance
- A Change Package to Reduce Hospitalizations
- HSAG Root Cause Analysis (RCA) 5-Whys Worksheet
- HSAG Plan-Do-Study-Act (PDSA) Worksheet
- Missed and Shortened Treatment Tracker Template (Excel)
- Monthly Hospitalizations Tracker (Excel)
- Monthly Hospitalizations Tracker (Word)
- Reasons Tracker (Excel)
Use the Reducing Hospitalizations Quality Improvement Activity (QIA) Monitoring forms in the facility’s Quality Assessment and Performance Improvement (QAPI) meetings to track, monitor, and assist with creating an action plan to reduce and address the following top hospital admissions and ED visit diagnoses:
- Transitions of Care Toolkit
- New to Dialysis? Hospital Discharge Checklist
- Nursing Home Staff Education: How to Care for Hemodialysis Patients Outside of Dialysis
- Long-Term Care Facility Information for Dialysis Residents
- Post-Hospitalization Checklist
- Medical Records Request Form Template
- Sit Down—Don't Stand: Questions About You
- Your Path to Better Health Resource
- Teach Back Resource
- Getting Creative to Break Down Barriers to Reducing Hospitalizations
- Hospital Risk Assessment
- How Dialysis Staff Can Impact Hospitalizations
- Vascular Access Appointment Form
- Communication Tips for Earning a Win
- Days Since Last Bloodstream Infection Poster
- What Is Your Plan? Patient Plan of Care Booklet (English/Spanish)
- Accessing Healthcare From a Federally Qualified Health Center (FQHC)
- 12 Good Reasons to Stay Through Treatment (English/Spanish)
- Don't Want to Feel This Way? Don't Miss Your Treatments!
- Don't Skip—Know the Facts
- We're Not Being Nosy—We Care! (English/Spanish)
- Play Offense—Avoid Hospitalization
- New to Dialysis? Hospital Discharge Checklist
- Where Should You Go for Medical Care?
- Take Charge of Your Health: Reduce Unnecessary Hospitalizations
- Your CVC: What You Need to Know!
Reference the resources below for information and tips on managing specific dialysis-related medical issues that commonly lead to hospitalizations and emergency room visits:
- Blood Pressure Zone Tool for Dialysis Patients
- Sepsis Zone Tool: My Plan to Identify Infection and/or Sepsis
- Sepsis Prevention Tip Sheet
- Infection Prevention Toolkit
- My Potassium Plan
- How to Keep Your Vascular Access Healthy
- Your Fluid Intake Matters!
- Educate Your Dialysis Patients About Anemia
- Patient to Patient: Let's Talk Fluids (English/Spanish)
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