Transcription of Care Coordination Best-Practices Toolkit
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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.
(Completed template included) This document provides an overview of current processes in place as well as the current state of readmission prevention strategies. Conducting a thorough assessment of the organization’s data and routine practices will aid in identifying areas that meet patient needs, and those that need improvement. 2.3
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