Skip to main content

Care Coordination

Medical Worker Provider

Additional Resources

Want more resources than what you find on this page?
You can find a full complement of care coordination assets in the main Care Coordination section. 

View Additional Resources

Accessing Official Rehospitalization Data Tip Sheet

This tip sheet will show you how to view your official rehospitalization data by accessing your Certification and Survey Provider Enhanced Reports (CASPER) Confidential Feedback Report.

View Resource

CMS' SNF Adverse Drug Event Trigger Tool

This tool was created by CMS as a resource document for SNFs containing necessary information for evaluating high risk medications/prevent unnecessary admissions or readmissions. It was designed to be a crosswalk that lists common potentially preventable ADEs, risk factors, triggers, and probes.

View Resource


(Interventions to Reduce Acute Care Transfers) is 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.

View Resource

Skilled Nursing Facility Resident Rehospitalization Tip Sheet

This tip sheet provides an overview of the SNF readmission measure, how to find your facility's measure, and probing questions aimed to helping your facility improve processes as they relate to rehospitalization.

View Resource

Transition from Hospital How-To Guide

This guide, developed by the Institute for Healthcare Improvement (IHI), focuses on the transfer of residents from the hospital to the nursing home setting and the associated transfer of responsibility between the care teams. (Nursing home is an umbrella term that includes skilled nursing facilities, long-term care facilities, acute rehabilitation facilities, and post-acute care facilities.)

View Resource