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.
• No advance directive or planning beyond do-not-resuscitate status. • Assuming the patient is the key learner and not including the family or a caregiver. • Not reinforcing the need to make and keep a follow-up appointment and/or not scheduling a follow-up appointment for the patient.
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