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Care Coordination Toolkit

Medical Worker Nurse Talking with Senior Patient
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Journey to Success: Steps to Care Coordination (PDF)

About Gap Analysis (PDF)

1. Five Key Areas Known to Reduce Avoidable Readmission (PDF)

2. Typical Failures in Discharge Planning (PDF)

3. Top Evidence-Based Interventions (PDF)

4. Gap Assessment—Acute Care (PDF). Download and complete.

    Gap Assessment—Emergency Department (PDF). Download and complete.

5. Gap/Root-Cause Analysis (PDF)

    Gap/Root-Cause Analysis (fillable PDF)

    Gap/Root-Cause Analysis (Word document)

6. Gap/Root-Cause Analysis Sample (PDF)

About Tools to Support Gap Analysis (PDF)

1. 5 Whys Tool for Root-Cause Analysis (fillable PDF)

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 Teach-Back

1. Practice Using Plain Language (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)

6. Teach-Back Employee Compentency Validation (PDF)

About Post-Acute Collaboratives (PDF)

1. Post-Acute Collaborative (PAC) Tip Sheet (PDF)

2. PAC Planning Sheet (PDF)

3. PAC Charter Template (PDF)

    PAC Charter Template (Word) 

4. PAC Agenda Kick-Off Template #1 (Word document)

5. PAC Agenda Kick-Off Template #2 (Word document)

6. PAC Agenda Kick-Off Template #3 (Word document)

About Patient Education—Zone Tools (PDF)

1. Heart Failure Zone Tool (PDF)

2. COPD Zone Tool (PDF)

3. All Zone Tools

HSAG HQIC Partnership