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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.

•Hospitals and other acute care providers currently track SNF rehospitalization rates to ensure quality of life/care during transfers from one care setting to another. •The State Survey and Certification Agency pays attention to rehospitalization under Ftag 483.12: Admission, Transfer, & Discharge. How to Find Your Measure

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