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Ohio Tools and Resources

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You will find downloads for specific Ohio tools and resources to assess your organization and assist you in managing your readmission rates.

Provider Facts and Tip Sheets 

Reducing ADEs—What Providers Can Do
This information sheet outlines high-risk medication-related readmissions in Ohio, with tips for providers to reduce the risk of ADEs for their patients.

Quick Tips for Prescribers—Anticoagulants
Tips for reducing ADEs involving anticoagulant medications

Quick Tips for Prescribers—Diabetic Agents
Tips for reducing ADEs involving diabetic agents

Quick Tips for Prescribers—Opioids
Tips for reducing ADEs involving opioids

ADE Facts for Hospitals

Reducing ADEs—Best Practices
This information sheet for Ohio outlines the importance of medication safety and hospital readmissions, with stats on high-risk medication readmissions in the state.

ADE Best Practice Reference Tool
Resource references for Medication reconciliation, bedside delivery, pharmacist counseling, post-discharge follow-up, medication therapy management, and medication history.

High-Risk Medications: Resource of the Month Information Sheets

Anticoagulants

Anticoagulants: Include These Key Elements for Warfarin Management at Discharge
A single sheet that includes a chart audit tool to see if patients in your care on warfarin have all five elements of warfarin management in their transfer documentation.

Warfarin: Why You Need It: How It's Monitored, Interactions to Recognize
Four pages that includes warfarin pocket cards with indications and interactions; staff member quiz for knowledge regarding warfarin interactions; and warfarin patient education competency validation checklist for staff members.

Diabetic Agents

Diabetic Hypoglycemia: Recognizing Common Symptoms and Managing a Hypoglycemic Event
Includes staff member education on the symptoms of hypoglycemia and a patient sheet on snacks to ward off a hypoglycemic event.

Diabetes Education: Use Teach-Back to Help Patients Successfully Manage Their Insulin 
A staff member sheet on how to use teach-back methods to educate patients on insulin basics, injection, storage, and syringe disposal.

Opioids

Opioids: Strong Warnings Against Combining Opioids for Pain, Cough Medicines, and Benzodiazepines
Provides a simple, single sheet overview of drug guidelines when prescribing opioids with sleeping aids, anti-anxiety medications, and cough medicines.

Opioids: Centers for Disease Control and Prevention (CDC) Prescribing Guidelines for Clinicians
This single sheet offers an overview of CDC tools for opioid prescribing guidance and links to flyers, posters, videos, and the Prescription Drug Monitoring Programs database.

National Resources for Medication Management

Medication Management Resources
Find a list of nationally recognized resources that include tools and best practices for medication management.

Tools for Care Coordination Collaboratives

Checklist for Care Coordination Collaborative
Partners will find guidance for Collaborative expectations 

Interventions to Improve Care Transitions and Reduce Readmissions Table
This table describes popular intervention tools, their uses, and provides links to these resources. Interventions include Project RED, BOOST, CTI, TCM, Bridge Model, GRACE, and INTERACT.

Tools for Hospitals

Community Intervention for Hospitals
This HSAG checklist is designed to help providers in the hospital setting to identify all available community resources.

Focus Group Sample Feedback Questions
Designed for home care, nursing home services, hospital, or physician office, HSAG provides these sample feedback questions, affording providers the opportunity to learn about patient problems after discharge or during an episode of care.

Population Health Worksheet
From HSAG, this worksheet is designed to help assess readmission data for your local hospital or community.

Readmission Interview Guide
Providing an opportunity for patients, families, and caregivers to share their perceptions about the hospitalization and post-discharge experience, this readmissions interview guide assists to care team in collecting this crucial feedback.

Tools for Nursing Homes

Community Interventions Checklist for Nursing Home and Rehab Facilities
This HSAG checklist is designed to help providers in the post-acute setting to identify all available community resources.

Focus Group Sample Feedback Questions
Designed for home care, nursing home services, hospital, or physician office, HSAG provides these sample feedback questions, affording providers the opportunity to learn about patient problems after discharge or during an episode of care.

Tools for Home Health Agencies

Why Home Health? Video
This three-minute animated video describes the benefits of home health services and why a physician should consider referring home health services for their discharged patients.

Community Interventions Checklist for for Home Health and Hospice
This HSAG checklist is designed to help providers in the home health setting to identify all available community resources.

Focus Group Sample Feedback Questions
Designed for home care, nursing home services, hospital, or physician office, HSAG provides these sample feedback questions, affording providers the opportunity to learn about patient problems after discharge or during an episode of care.

HHQI QAPI Resources
Home Health Quality Improvement (HHQI) has created Quality Assurance & Performance Improvement (QAPI) materials derived from the Centers for Medicare & Medicaid Services (CMS)  Home Health Conditions of Participation (CoP). 

   QAPI 101
   - Home Health QAPI Fact Sheet

   Hospitalization Performance Improvement Project (PIP)
   - PIP Tool: Hospitalizations
   - Sample Hospitalizations PIP

   Medication Management PIP
   - PIP Tool: Medication Management
   - Sample Medication Management PIP

   Cardiovascular Health PIP
   - PIP Tool: Cardiovascular Health
   - Sample Cardiovascular Health PIP

   QAPI Canvas

Other Tools

7-Day Readmissions Checklist Audit Tool
This one-page audit tool prompts clinical or quality staff members to review a list of factors commonly attributed to preventable hospital readmissions. Obtain insight into why a readmission within 7 days of a hospital discharge has occurred and how it could have been avoided. Identify patterns and trends among readmitted patients, existing gaps in the organization’s current discharge processes, and opportunities for performance improvement. 

Instruction Sheet for the 7-Day Readmissions Checklist Audit Tool

Performance Improvement Tracker Tool
This worksheet is a companion document to the 7-Day Audit Tool to aggregate factors believed to be high risk and contributing to readmissions over time. Enter the results of readmission audits each quarter with a goal of identifying common trends, patterns, and themes. Review current processes surrounding the pre-hospital preparation and post-hospital transitions of patients, and focus process improvement efforts that close the gaps found. 

Instruction Sheet for the Performance Improvement Tracker Tool

 

Quality Improvement Workbook
Find all the tools you need to plan your quality improvement journey, from how to form a team, discovering root causes, creating a plan, and assessing your plan.

Organizational Assessment Summary
Use this worksheet to help establish focus areas for your organization.

5 Whys Worksheet
This worksheet will help your organization identify the root cause of your initial problem.

5 Key Areas Overview
Tips on areas known to reduce avoidable readmissions, including discharge planning, medication management, patient/family engagement, transition care support, and transition communications.

Reflective Discussion Questions
This worksheet will help stimulate discussion to identify key areas of opportunity and next steps.

SWOT Analysis Worksheet
Identify your organization's internal and external strengths, weaknesses, opportunities, and threats.

Typical Failures in Discharge Planning
Help identify possible discharge failures in discharge planning, medication management, patient/family engagement, transition care support, and transition communications.

Reducing Readmissions: Organizational Assessment/Root Cause Analysis
As a first step to reducing readmissions, HSAG advises conducting an organizational assessment and has designed a set of instructions to help providers do so.

7-Day Readmissions Checklist Audit Tool
This one-page audit tool prompts clinical or quality staff members to review a list of factors commonly attributed to preventable hospital readmissions. Obtain insight into why a readmission within 7 days of a hospital discharge has occurred and how it could have been avoided. Identify patterns and trends among readmitted patients, existing gaps in the organization’s current discharge processes, and opportunities for performance improvement. 

Instruction Sheet for the 7-Day Readmissions Checklist Audit Tool

Performance Improvement Tracker Tool
This worksheet is a companion document to the 7-Day Audit Tool to aggregate factors believed to be high risk and contributing to readmissions over time. Enter the results of readmission audits each quarter with a goal of identifying common trends, patterns, and themes. Review current processes surrounding the pre-hospital preparation and post-hospital transitions of patients, and focus process improvement efforts that close the gaps found. 

Instruction Sheet for the Performance Improvement Tracker Tool

Health Literacy Toolkit
Scientific studies have shown the correlation between patients’ health literacy level and health outcomes. This toolkit provides resources for assessment, communication, patient education, community support, and medication management.

Medication Reconciliation Teach-Back Questions
A worksheet for a patient education program.

Quality Improvement Workbook
Find all the tools you need to plan your quality improvement journey, from how to form a team, discovering root causes, creating a plan, and assessing your plan.

Medication History Toolkit
This toolkit can assist in medication reconciliation.

Zone Tools for Patients 
Find handouts to download for asthma, chronic obstructive pulmonary disease (COPD), diabetes, heart disease, kidney health, and much more.

You can also find links to national resources that include care coordination in a number of areas:

All Care Coordination National Resources

   Heart Failure

   Medicare Initiatives

   Medication Management

   Organizations

   Reports and Articles

   Teach-Back Training

   Tools and Guides