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Skilled Nursing Facility Care Coordination Toolkit - HSAG

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.

patients directly to reimbursement strategies. Improving avoidable 30-day readmission rates from SNFs is vital for financial stability, quality metrics , and the patient experience. This section contains tools specifically tailored to improving quality within the skilled setting.

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Transcription of Skilled Nursing Facility Care Coordination Toolkit - HSAG

1 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.

2 SNF Shared Best Practices to Reduce Potential Preventable Readmissions SNF Transfer Checklist SNF Pre-Admission Huddle Equipment Checklist SNF Re-Hospitalization Risk Assessment Page | 2 Patient Education Tools and Resources .. Zone Tools Heart Failure Sepsis COPD Welcome to SNF Brochure Guidelines Welcome to SNF Brochure Template Teach-Back .. Teach-B ack Can Help Practice Using Plain Language Teach-B ack Sentence Starters Teach-Back Validation Tool This material was prepared by Health Services Advisory Group, the Medicare Quality Innovation Network-Quality Improvement Organization for Arizona, California, Florida, Ohio, and the Virgin Islands, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the Department of Health and Human Services.

3 The contents presented do not necessarily reflect CMS policy. Publication No. QN-11 SOW-XC-07092019-01 Executive Summary Reducing readmissions in Skilled Nursing facilities (SNFs) is a top priority for the Centers for Medicare & Medicaid Services (CMS). Research shows that more than 20 percent of Medicare beneficiaries discharged from a hospital to a SNF will return to a hospital within 30 days, costing Medicare more than $4 billion per These returns are often due to potentially preventable conditions, such as dehydration, infections, medication errors, and unaddressed social needs. As your CMS Quality Improvement Organization (QIO), Health Services Advisory Group (HSAG) is committed to improving the quality of care delivered in each state it serves.

4 This includes the self-directed Reducing Readmissions Preparation Program (RRPP), which is designed to help improve knowledge on the new readmission quality measures, identify strategies to prevent readmissions, and help facilities be a preferred provider to their local hospitals. HSAG knows organizations like yours are committed to ensuring that residents have the necessary tools and care in place prior to discharge. Your efforts provide residents the opportunity to heal in the home setting with loved ones. Employing these tools can help improve organizational quality metrics and maximize financial incentives. HSAG hopes the information in this Toolkit will assist you and your organization improve care Coordination and reduce readmissions.

5 For assistance or further information, please reach out to your state s HSAG office. Nationally, readmissions cost Medicare $26 billion dollars annually, of which $17 billion are potentially Telephone Email Arizona California Florida Ohio Find more about care Coordination at: Sources: V, Intrator O, Fen, Z, Grabowski DC. The revolving door of rehospitalization from Skilled Nursing facilities. Health Affairs. 2010: 29(1). Available at: J. Medicare Fines 2,610 Hospitals In Third Round of Readmission Penalties. Kaiser Health News. 2014. Available at: Accessed March 11, 2019. Readmission Prevention Page | Readmission Prevention Skilled Nursing facilities (SNFs) play a vital role in the healthcare continuum.

6 As healthcare practices shift to achieve improved care with lower cost, these organizations patient populations may shift to more acutely ill patients. On October 1, 2018, CMS began linking the return of acute patients directly to reimbursement strategies. Improving avoidable 30-day readmission rates from SNFs is vital for financial stability, quality metrics, and the patient experience. This section contains tools specifically tailored to improving quality within the Skilled setting. Overview of Resources Form Purpose Rationale Skilled Nursing Facility Resident Rehospitalization Tip Sheet Provides an overview of the readmission measure in conjunction with practices aimed at preventing readmissions.

7 Readmissions play a vital role in quality measures for the Facility . Ensuring best practices are in place to minimize the risk of readmission prior to discharge is essential. In addition, SNFs should track and trend readmission rates to evaluate in-place tactics of prevention and a measure of overall quality. Top 10 Things You Should Know about the Skilled Nursing Facilities Readmission Measure Provides a high-level overview of the top 10 things CMS identified as aspects you should know about the SNF readmission measure. To ensure your Facility understands what data CMS is evaluating and how those calculations are made. Understanding this measure will help to determine the impact it will have on your Facility .

8 SNF-RM Exclusion Criteria Provides a summary of the unique circumstances that are excluded from SNF-RM criteria. Understanding the exclusion criteria will improve the accuracy of your internal data tracking and help determine the financial impact of the SNF-RM. Accessing Official Rehospitalization Data Tip Sheet Step-by-step instructions on how to access your CASPER report. This report provides data that may affect your Facility s standing regarding value-based purchasing. Tracking and trending these data will help ensure there are no surprises when the penalties are determined. Page | Reducing Readmissions Preparation Program Nursing Home Readmission Assessment (Pre & Post) An assessment tool to evaluate what prevention elements your organization has or does not have in place to help reduce readmissions.

9 An assessment provides a measure of your organization s current performance and provides direction toward processes that can be leveraged for improvement. QAPI Worksheet to Create a Performance Improvement Project (PIP) Sample A completed sample PIP related to improving accuracy of assessment of patient acuity at admissions to reduce readmissions. Knowing where to get started with improvement projects can feel overwhelming. This sample PIP is available for adoption or to help guide your efforts as you complete your own PIP. Strategy Tree to Address Challenges Sample The strategy tree sample outlines possible tactics and tasks to be implemented to successfully complete the PIP related to improving accuracy of assessment of patient acuity.

10 Often, the strength of an intervention is determined by how well it is executed. This tool helps ensure strong strategy development and implementation of interventions. Find more tools for care Coordination at: Skilled Nursing Facility Resident Rehospitalization Tip SheetMeasure Overview The Skilled Nursing Facility (SNF) readmission measure estimates risk-standardized rate of all-cause, unplanned hospital readmissions ofMedicare SNF beneficiaries within 30 days of discharge from their priorproximal acute hospitalization. Hospital readmissions are identified through Medicare within a 30-day window are counted regardless of whetherthe beneficiary is readmitted to the hospital directly from the SNF or hasbeen discharged from the SNF.


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