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Care Coordination Best-Practices Toolkit

Care Coordination Best-Practices ToolkitCollaborating with partners, providers, patients, families,and caregivers to improve and lower healthcare overview of care Coordination best practices to avert hospital readmissionsDownload available at: | 1 Table of Contents Executive Summary .. Organizational Assessment .. Five Key Areas Known to Reduce avoidable Readmissions .. Typical Failures in Discharge Planning .. Organizational Assessment Summary and Sample .. Admission Assessment Tool .. Discharge Observation Tool .. Preparing for Change .. Five Whys Tool for Root Cause Analysis .. Goal Setting Worksheet .. Strategy Tree Form and Readmission Reviews .. Interview with Patients, Family Members and Care Team Members .. 7- Day Readmission Checklist and Audit Tool and Instructions .. Medication Management .. Reducing Adverse Drug Events .. Reducing Anticoagulants Adverse Drug Events Warfarin .. High-Risk Medications: Resource of the Month Warfarin.

Reduce Avoidable Readmissions This document provides an overview of the common causes of preventable readmissions. As each organization begins to look at readmission prevention, it is important to recognize common themes that have been proven to improve readmissions. 2.1 Typical Failures in Discharge Planning

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