Readmissions and Hospitalizations

The Network, in accordance with the Centers for Medicare & Medicaid Services (CMS) and the National Transition of Care Coalition (NTOCC), is trying to increase awareness and action in the beneficiary and provider communities of the importance of safe and effective care transitions between all settings to reduce medication errors and enhance clinical outcomes.

Please use these tools to improve care transitions in your community:

HSAG RCA 5-whys Worksheet (PDF)

HSAG PDSA Worksheet (PDF)

National Care Transitions Key Messages (PDF)

Provides key messages and taglines that promote patient and family engagement and convey the benefits of coordinated care for use with both providers and healthcare systems and patients and families.

Take Charge of Your Health: Reduce Unnecessary Hospitalizations Booklet
Your ESRD • Your Care • Your Priority (PDF)

Provides practical and relevant information on how patients can protect themselves against the need for unnecessary hospitalizations. Click on your Network-specific version below:

• Network 7
• Network 13
• Network 15
• Network 17

You can also share the following stand-alone handouts with patients. They are taken from the Take Charge of Your Health: Reduce Unnecessary Hospitalizations booklet and concentrate on a primary topic with an emphasis on working as a team.

• We’re Not Being Nosey—We Care!
• Communication TIPS for Earning a WIN
• Play Offense—Avoid Hospitalization

National Care Transitions Commitment Form

Provides facilities with a means of committing to make care transitions a priority by including discussions in meetings, improving communications with care partners, and using CMS resources and tools to coninually educate both staff and patients about the importance of reducing unnecessary hospitalizations/readmissions. Click on your Network-specific version below:

• Network 7
• Network 13
• Network 15
• Network 17