Care coordination is a key priority for the Centers for Medicare & Medicaid (CMS) to improve quality and achieve safer and more effective care. However, gaps in care, such as poor communication and ineffective discharge processes, remain a challenge.
To address these gaps, HSAG provides evidence-based strategies, resources and training needed to improve care coordination.
Medication Management
Journal Articles
Pharmacy-led medication reconciliation. Effectiveness of pharmacist-led medication reconciliation programmes on clinical outcomes at hospital transitions: a systematic review and meta-analysis.
Discharge Medication reconciliation by Pharmacists to improve Transitions following Hospitalization (DEPTH). Readmission rates and cost avoidance associated with pharmacist-led discharge medication reconciliation.
Tools
IHI Medication Reconciliation Toolkit. Institute for Healthcare Improvement (IHI) How-to Guide: Prevent Adverse Drug Events by Implementing Medication Reconciliation
MATCH Medication Reconciliation Toolkit. Medications at Transitions and Clinical Halndoff (MATCH)
Medication Discrepancy Tool. By Eric Coleman, MD
ASHP-APhA Medication Management in Care Transitions Best Practices. From American Society of Health-System Pharmacists and American Pharmacists Association. Note pages 29-40.
Discharge Planning
Readmission Tools
Readmission Interview Tool with Patients, Family Members, and Care Team Members (PDF). From the HSAG Care Coordination Toolkit.
Social Determinants of Health Tools
Health Equity Organizational Assessment (HEOA). A downloadable PDF form that assesses your hospital’s ability to identify and address health disparities. From HSAG.
Hospital Guide to Reducing Medicaid Readmissions (PDF). from the Agency for Healthcare Rsearch and Quality (AHRQ).
Guide to Reducing Disparities in Readmissions (PDF). From the Centers for Medicare & Medicaid Services (CMS).
CMS Strategic Plan Pillar: Health Equity (PDF). From CMS.
Health Equity Snapshot: A Toolkit for Action (PDF). From the American Hospital Association (AHA).
Achieving Health Equity: A Guide for Healthcare Organizations (whitepaper). From The Institute for Healthcare Improvement (IHI).
Patient Engagement
Tools
Zone Tools. HSAG patient education post-discharge self-care tools.
Tools
Always Use Teach-Back! (website). Training and tools.
Teachback.org (website). Training and tools.
HSAG Care Coordination Toolkit handouts - Teach-Back, section 5. Includes Plain Language Terms, Teach-Back Sentence Starters, flyers for Self-Training, Reminder to Use Teach-Back posters, and Employee Compenency Validation.
Tools
Anticoagulation Patient Toolkit. A consortium-developed quick reference for anticoagulation.
A Patients Guide to Taking Warfarin. From the American Heart Association.
Care Coordination Collaboration
Tools
About Post-Acute Collaboratives. HSAG Intro page.
Post Acute Collaboratives section in the HSAG Care Coordination Toolkit
Tools
SBAR Toolkit (website). Institute for Healthcare Improvement (IHI), Situation, Background, Assessment, Recommendation (SBAR) toolkit. New visitors to IHI may be asked to create a sign-in.
SNFs
Long-Term Care SBAR Resources (website). Agency for Healthcare Research and Quality (AHRQ).
Quality Improvement Tools
Tools
Gap/Root Cause Analysis (fillable PDF)
Prioritization Matrix (fillable PDF)
7-Day Readmission Checklist and Audit Tool and Instructions (PDF)
Strategy Tree (fillable PDF)
Care Coordination Evidence-Based Models
Better Outcomes for Older Adults Through Safe Transitions (BOOST)
Care Transitions Intervention® (CTI) (Coleman Model)
IDEAL Discharge Planning Agency for Healthcare Research Quality (AHRQ)
Project Re-Engineered Discharge (RED)
Hospital Guide to Reducing Medicaid Readmissions (PDF), AHRQ
SNFs
Interventions to Reduce Acute Care Transfers® (INTERACT®)
