All Providers
- Modified LACE Tool (HSAG)
- Bulletin: Reducing Nonurgent Emergency Department (HHS)
- Age-Friendly Health System (IHI)
Hospital Readmissions
- 30-Day Readmission Audit Workbook (HSAG)
- 7-Day Readmission Audit Tool Instructions (HSAG)
- Readmission Interview Tool (HSAG)
- Teach-Back Starter Sentences (HSAG)
- Social Determinants of Health That Affect Your Patients (HSAG)
- Nursing-Led Transitional Care Model (Univ. of PA)
- Improving Transitions from the Hospital to the Clinical Office Practice to Reduce Avoidable Rehospitalizations (STAAR)
Nursing Homes
- Interventions to Reduce Acute Care Transfers (INTERACT) (Pathway Health)
- Re-Engineered Discharge (RED) Toolkit (AHRQ)
