1. Five Key Areas Known to Reduce Avoidable Readmission (PDF)
2. Typical Failures in Discharge Planning (PDF)
3. Top Evidence-Based Interventions (PDF)
4. Care Transitions Assessment—Acute Care, download and complete.
Care Transitions Assessment—Emergency Department, download and complete.
Care Transitions Assessment—Skilled Nursing Facility, 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 (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 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 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)
