1. Five Key Areas Known to Reduce Avoidable Readmission (PDF)
2. Typical Failures in Discharge Planning (PDF)
3. Top Evidence-Based Interventions (PDF)
4. Performance Improvement Project (PIP) (PDF template)
5. PIP Sample (PDF)
6. Care Transitions Assessment—Skilled Nursing Facility, download and complete.
7. Gap/Root-Cause Analysis (fillable PDF)
Gap/Root-Cause Analysis (Word document)
8. Gap/Root-Cause Analysis Sample (PDF)
About Tools to Support Gap Analysis (PDF)
1. 5 Whys Tool for Root-Cause Analysis (PDF fillable form)
2. 5 Whys Tool for Root-Cause Analysis—Sample (PDF)
3. 7-Day Readmission Checklist and Audit Tool and Instructions (PDF)
4. Readmission Interview with Patients, Family Members and Care Team Members (PDF)
About Goal and Strategy Development (PDF)
1. Key Findings: Goal Development Worksheet Using SMART (PDF) (Fillable form)
2. Strategy Tree Form (PDF) (Fillable form)
3. Strategy Tree Sample (PDF)
About Readmission Prevention (PDF)
1. Rehospitalization Risk Assessment (PDF)
2. Pre-Admission Huddle (PDF)
3. Nursing Home Transfer Checklist (fillable PDF)
About Teach-Back (PDF)
1. Plain Language Terms (PDF)
2. Teach-Back Sentence Starters (PDF)
3. Teach-Back Flyers for Self-Training (PDF)
4. Reminder to Use Teach-Back (posters) (PDF)
5. Teach-Back Training Flyer (template) (PDF)
About Patient Education—Zone Tools (PDF)
1. Heart Failure Zone Tool (PDF)
2. COPD Zone Tool (PDF)
3. Welcome to the Nursing Home FAQs (Word template download)
