Tools/Interventions

Discharge Risk Assessment tool*

Coaching Materials for CHF*+

Coaching Materials for COPD*+

Coaching Materials for Pneumonia*+

Coaching Materials for AMI*+

DVT Warning Signals for patients*
+

Discharge Risk Tracking Tool


Organization Assessment Tool

Readmission Report Tool


"My Health Book" Personal Health Record

Hospital to Nursing Home Transfer Form

Nursing Home to Hospital Transfer Form

Resources

CMS Hospital Readmissions Reduction Program (HRRP) - An Overview (PDF of October 2011 PPT)

Project BOOST Better Outcomes for Older Adults through Transitions) -Visit www.hospitalmedicine.org and type Boost in the search box.

Dr. Eric Coleman's Transition Coach Model - www.caretransitions.org

R.E.D. (Re-engineered Hospital Discharge) - This is part of a randomized controlled trial at Boston Medical Center funded by the Agency for Healthcare Research and Quality. www.bu.edu/fammed/projectred
/index.html

Videos of LHA Sessions on Reducing Rehospitalizations (eQHealth Solutions YouTube channel)

Video of eQHealth Director of Quality, Laurie Robinson at CMS National Conference on Care Transitions in Baltimore (12.3.10)

The Remington Report, July/August 2010 issue features the Baton Rouge Care Transitions project.

HealthLeaders-InterStudy features Care Transitions projects in Louisiana, Alabama and Georgia. (August 2009)

Care Transitions Project Director Laurie Robinson featured on WJBO Radio "Canon Hospice Community Health Show" (8.1.09)
Segment 1 (4.2 mb) | Segment 2 (4.5 mb)| Segment 3 (3 mb) | Transcript*

6.4.09 (Baton Rouge, LA) - WAFB-TV Healthline story on Care Transitions coaching at Our Lady of the Lake Regional Medical Center.
Click for video | Click for transcript

+ These materials are intended to be used as supplemental tools during face-to-face coaching sessions. The materials should not be considered complete interventions, and the use of these materials outside of face-to-face coaching interactions should be used strictly for educational purposes. These tools are not designed to replace health care provider advice.  Any patient use of the information or materials for post-discharge care planning should be communicated with a patient’s attending or primary care physician.

Quality Immprovement Organization logo

Community Coalitions

Care Transitions
Learning & Action Network

LHA/eQHealth
Reducing Readmissions Training Sessions - Monthly Call Calendar


Community-Based Care Transitions Program (CCTP)

End of Life Care (LaPOST)

Tools & Resources

2011 Louisiana Quality Summit & Awards Wrap-up
PLUS Award Winners

 

 

 

 

 

 

 

 

 

 

 

 

 


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