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Care Coordination

Provider Medical Team Looking at Xray

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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(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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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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