Transcription of Care Coordination Best-Practices Toolkit - HSAG
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Care Coordination Best-Practices Toolkit - HSAG
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.
and planning for the discharge. • Lack of understanding of the patient’s physical and cognitive functional health status that may result in a transfer to a care setting that does not meet the patient’s needs. • Not addressing the whole patient (underlying depression, etc.). • No advance directive or planning beyond do-not-resuscitate ...
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