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Skilled Nursing Facility Care Coordination Toolkit

Collaborating with partners, providers, patients, families,and caregivers to improve and lower healthcare Nursing Facility care Coordination ToolkitAn overview of care Coordination best practices to avert hospital readmissionsDownload available at: Page | 1 Table of Contents Executive Summary Readmission Prevention .. Skilled Nursing Facility (SNF) Resident Rehospitalization Tip Sheet Top 10 Things to Know About SNF Readmissions Measure SNF Readmission Exclusion Criteria Accessing Official Rehospitalization Data Tip Sheet Readmission Pre/Post Assessment Readmission PIP Sample Readmission Strategy Tree Sample Reducing Adverse Drug Events .. Warfarin: Why you Need it, How it s Monitored, Interactions to Recognize Reducing Diabetic Agents Adverse Drug Events Diabetes Education: Use Teach-Back to Help Patients Successfully Manage Their Insulin Opioids: Centers for Disease control and Prevention (CDC)Prescribing Guidelines for Clinicians Readmission Tools.

Opioids: Centers for Disease Control and Prevention (CDC)Prescribing Guidelines for Clinicians . ... this toolkit will assist you and your organization improve care coordination and reduce readmissions. For assistance or further information, please reach out to your state’s HSAG office. Nationally, readmissions cost

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Care Coordination Best-Practices Toolkit

www.hsag.com

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

  Reduces, Avoidable, Reduce avoidable

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