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California Tools and Resources

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You will find downloads for specific tools and resources to assess your organization and assist you in managing your readmission rates.

Provider Tools

Reducing ADEs—What Providers Can Do
This information sheet outlines high-risk medication-related readmissions in California, with tips for providers to reduce the risk of ADEs for their patients.

Quick Tips for Prescribers—Anticoagulants
Tips for reducing ADEs involving anticoagulant medications

Quick Tips for Prescribers—Diabetic Agents
Tips for reducing ADEs involving diabetic agents

Quick Tips for Prescribers—Opioids
Tips for reducing ADEs involving opioids

Other ADE Tools

Reducing ADEs—Best Practices
This information sheet for California outlines the importance of medication safety and hospital readmissions, with stats on high-risk medication readmissions in the state.

ADE Best Practice Reference Tool
Resource references for Medication reconciliation, bedside delivery, pharmacist counseling, post-discharge follow-up, medication therapy management, and medication history.

High-Risk Medications: Resource of the Month Information Sheets

Anticoagulants

Anticoagulants: Include These Key Elements for Warfarin Management at Discharge
A single sheet that includes a chart audit tool to see if patients in your care on warfarin have all five elements of warfarin management in their transfer documentation.

Warfarin: Why You Need It: How It's Monitored, Interactions to Recognize
Four pages that includes warfarin pocket cards with indications and interactions; staff member quiz for knowledge regarding warfarin interactions; and warfarin patient education competency validation checklist for staff members.

Diabetic Agents

Diabetic Hypoglycemia: Recognizing common Symptoms and Managing a Hypoglycemic Event
Includes staff member education on the symptoms of hypoglycemia and a patient sheet on snacks to ward off a hypoglycemic event

Diabetes Education: Use Teach-Back to Help Patients Successfully Manage Their Insulin
A staff member sheet on how to use teach-back methods to educate patients on insulin basics, injection, storage, and syringe disposal.

Opioids

Opioids: Strong Warnings Against Combining Opioids for Pain, Cough Medicines, and Benzodiazepines
Provides a simple, single sheet overview of drug guidelines when prescribing opioids with sleeping aids, anti-anxiety medications, and cough medicines.

Opioids: Centers for Disease Control and Prevention (CDC) Prescribing Guidelines for Clinicians
This single sheet offers an overview of CDC tools for opioid prescribing guidance and links to flyers, posters, videos, and the Prescription Drug Monitoring Programs database.

Organizational Assessment Summary
Use this worksheet to help establish focus areas for your organization.

5 Whys Worksheet
This worksheet will help your organization identify the root cause of your initial problem.

5 Key Areas Overview
Tips on areas known to reduce avoidable readmissions, including discharge planning, medication management, patient/family engagement, transition care support, and transition communications.

7-Day Readmission Checklist
Obtain insight into why a readmission within 7 days has occurred and how it could have been avoided.

Admission Assessment Observation Tool
Discover the current process to identify patients for observation during admission assessment with this tool.

Discharge Observation Tool
Discover what went well and what did not work as planned and predicted by observing the patient on the last day of acute care hospitalization.

Interviews With Patients, Family Members and Care Teams
Use this tool to conduct interviews with key team members regarding a patient's readmission

Reflective Discussion Questions
This worksheet will help stimulate discussion to identify key areas of opportunity and next steps.

Strategy Tree
This template will help you assess readmission challenges, set goals, develop a strategy, and implement tactics and tasks.

SWOT Analysis Worksheet
Identify your organization's internal and external strengths, weaknesses, opportunities, and threats.

Typical Failures in Discharge Planning
Help identify possible discharge failures in discharge planning, medication management, patient/family engagement, transition care support, and transition communications.

Tools Especially for Skilled Nursing Facilities

Skilled Nursing Facility Shared Best Practices to Reduce Potentially Preventable Readmissions (PPR)
This checklist offers numerous best practice ideas and interventions to assist with reducing avoidable hospital readmissions.

Skilled Nursing Facility Rehospitalization Risk Assessment
This check sheet will help assess a patient's readmission risks for chronic conditions, high-risk medications, and other factors common to readmitted patients.

Skilled Nursing Facility Transfer Checklist
This check sheet can be used for patients transferring to the next level of care (i.e., hospital to SNF, SNF to hospital, etc.) to ensure that all patient documentation is present upon transfer.

Pre-Admission Huddle: Equipment/Special Care Need for Skilled Nursing Facility Resident
This checklist indicates any special equipment or care needs a SNF resident may need.

Behavioral Health

Learn about behavioral health screenings and care transitions here.

Find resources for inpatient psychiatric facilities here.

Find webinars and "Top 10" intervention here.

Zone Tools for Patients 
Find handouts to download for asthma, chronic obstructive pulmonary disease (COPD), diabetes, heart disease, kidney health, and much more.

Teach-Back Tools
Discover tools and downloadable worksheets for teach-back, including handouts for competency, teach-back observation, coaching, and video resources here.

Teach-Back Starter Sentences

Teach-Back Plain Language

Teach-Back Heart Failure Starter Sentences

Teach-Back Heart Failure Plain Language

Health Literacy Toolkit
Scientific studies have shown the correlation between patients’ health literacy level and health outcomes. This toolkit provides resources for assessment, communication, patient education, community support, and medication management.

Readmissions Penalties Are Coming. Are You Ready?

Did you know that Medicare is changing the reimbursement structure for nursing homes starting October 2018? A new factor that will contribute to your nursing home reimbursement are hospital readmissions. Are you ready?

Learn more and find materials

Steps in the preparation journey

Sign up

Find links to national resources, including tools and articles, for care coordination to assist hospitals, nursing homes, home health agencies, hospices, and physicians in reducing 30-day avoidable readmissions.

All Care Coordination National Resources

   Heart Failure

   Medicare Initiatives

   Medication Management

   Organizations

   Reports and Articles

   Teach-Back Training

   Tools and Guides