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Care Coordination

Medical Team Provider in Home with Senior Patients
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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. 

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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.

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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.

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INTERACT

(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.

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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.

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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.)

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