Readmission Collaborative

Events

FHA is bringing together workgroups to identify, share and discuss best practices and evidence-based interventions. To join one of these workgroups, register to become part of the collaborative today!

FHA, FHCA, and Alliant Health Solutions Readmission Prevention Series

• Sharing Infection Status
• Communicating Medication Information
• SNF to ED: To Go or Not Go
• Role of Advanced Care Planning & Palliative
• Engaging Patients and Families
• Improving Information Sharing Between Settings
• Stroke Readmissions and Health Equity
• Tools and Resources to Prevent Readmissions
• Importance of Knowing Nursing Home Capabilities
• Leveraging Health Information Exchange: SNF Dashboard
• SDoH Impact on Reducing Readmissions: Post Discharge Support Resources from the Area Agency on Aging and Community Care Hubs

Resources

Tools, guides, and data resources that support hospital efforts to understand, prioritize, and reduce avoidable readmissions across the continuum of care.

Discharge Planning

• Ready–Set–Go – Guide designed with patient and family partners to enhance discharge planning during admission, bedside rounds, and discharge
• Patient Engagement Map – Guide to help patients and families participate in discharge planning from admission through discharge
• Discharge Phone Call Menu of Change Ideas – Menu of change ideas to optimize discharge phone calls as a readmission reduction strategy

What to Expect Guides

Ready-to-use materials designed to help patients and families understand the full range of post-acute care options.

What to Expect Guides Toolkit

A comprehensive resource designed to help hospitals educate patients and families on post-acute care options following discharge. This toolkit brings together guides that helps patients understand their options and make informed decisions that support recovery and reduce readmissions.

Read More

• What to Expect from Hospice Care: English | Spanish
• What to Expect from Home Health Care Services: English | Spanish
• What to Expect When Going to a SNF: English | Spanish
• What to Expect from Private Duty Home Care Services: English | Spanish
• What to Expect from Inpatient Rehab: English

Medication Reconciliation

• Medication Reconciliation Discovery Tool – Fillable document for auditing charts of 5–10 admitted and discharged patients for medication reconciliation best practices
• Discharge Medication Menu of Change Ideas – Menu of change ideas to improve medication accuracy and access as a readmission reduction strategy
• Medication Review Tip Sheet – Patient-facing tips for reviewing medications with healthcare providers
• Medication Review Tip Sheet - Spanish – Spanish-language guide to help patients and families prepare for and participate in medication reviews with their healthcare providers

Care Transitions

• Billable Transitional Care Management Resources – Information on hospital billable care transition services, including discharge phone calls and follow-up appointments
• TCM Business Case Calculator – Excel spreadsheet for predicting the cost and benefit of establishing hospital-based billable TCM services
• Super-Utilizer Coaching Package: What's in your Toolkit? – Toolkit to support care teams in managing high-utilizer patients and reducing readmissions

Follow-Up

• Follow-Up Appointment Menu of Change Ideas – Menu of change ideas to optimize the follow-up appointment process as a readmission reduction strategy
• Readmissions Interview Guide – Describes how to prepare for and conduct an interview of a readmitted patient

Tracking and Auditing

• Readmission Discovery Tool – Fillable document for auditing charts of 5–10 readmitted patients for care transition best practices
• Readmission Prioritization Worksheet – Excel spreadsheet for tracking contributing factors to readmissions and identifying trends

Post-Acute Resources

• Skilled Nursing Facility/Nursing Home Resources
• Nursing Home Readmission Assessment (Smartsheet) – Online assessment tool for the Reducing Readmissions Preparation Program
• Nursing Home Readmission Assessment (PDF) – Fillable PDF version of the Reducing Readmissions Preparation Program assessment
• Home Health Resources
• Complete Home Health Care Reducing Readmissions Toolkit – Comprehensive toolkit to support home health agencies in reducing readmissions
• Home Health Readmission Assessment – Assessment tool for home health agencies participating in readmission reduction efforts 

Zone Tools

Patient-facing, one-page, color-coded tools designed to help patients and caregivers manage chronic conditions by recognizing symptoms and knowing when to seek care.

• Chronic Kidney Disease (CKD): English | Spanish
• COPD with Symptom Tracker: English | Spanish
• Diabetes: English | Spanish
• Heart Failure with Weight Log: English | Spanish
• High Blood Pressure with BP Log: English
• Anticoagulation Medication: English | Spanish
• COVID-19 Self-Management: English | Spanish
• Pneumonia: English | Spanish
• Post-Dialysis: English
• Renal Failure with Weight Log: English
• Self-Management: Depression: English | Spanish
• Sepsis/Infection: English | Spanish
• Total Hip Replacement: English
• Total Knee Replacement: English
• Warning Signs of Stroke: English | Spanish
• Where Should I Go for Care: English | Spanish

Discussion Groups

Participating in these targeted discussion groups provides hospital teams with meaningful opportunities to learn, collaborate, and strengthen strategies that reduce avoidable readmissions through sharing real-world experiences. To join one of the discussion groups below, please reach out to Kimmie Cunniff at [email protected].