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Self-Help for Patients & Their Families

Follow four simple steps proven to help patients make a safe transition across care settings or when leaving care to return home.

Patients with heart problems are among those most likely to be readmitted to a hospital. Learn how to protect your heart!

The following list represents just the tip of the iceberg for resources related to reducing avoidable hospitalizations and improving the safety of care transitions.

Our team is available to help healthcare providers and community organizers across Idaho and Washington locate the tools best suited to their unique needs; please contact us if the sampling posted here does not address your situation.

Jump down to a category of resources:

Webinar Archive

Assessing Risk for Rehospitalization

Communication Standards

Educating Patients & Their Families

Integrating Behavioral Health into Care Transitions

New! Infection Prevention (various care settings)

Interventions Specifically Designed for Long-Term Care Settings

Interventions Specifically Designed for Patients Experiencing Homelessness

Preventing Adverse Drug Events

Managing Change

Penalties, Incentives & Billing

Quality Improvement Planning & Measurement

Other Resources

Assessing Risk for Rehospitalization

Disparities, Superutilizers and New Approaches for Health Equity
September 2015 webinar hosted by Qualis Health
We all have limited resources. With changes to reimbursement driven by penalty programs and value-based payment, we must ensure our interventions to reduce avoidable hospitalizations and readmissions affect our key measures. Disease/diagnosis-based targets can only take us so far—and may not have the required impact.


Because a patient's race is often a predictor of readmission risk, interventions to combat racial disparities in care are important.

Below, we have provided links to several nationally recognized, evidence-based tools for assessing a patient's risk of rehospitalization. To determine the best tool for your healthcare organization, consider the degree to which it:

  • Is practical for day-to-day use
  • Has been validated for use in your own setting
  • Accurately predicts risk
  • Focuses on problems you can impact
  • Incorporates social factors and functionality
  • Links to protocols and actions already in place, or can be put into place, at your facility

How-to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations
Note: To access this guide, the Institute for Healthcare Improvement requires readers to log in. (Registration is free.)
Designed to support hospital-based teams and their community partners in co-designing and implementing improved care processes; recommends key changes, provides strategy ideas and measurement tools; includes case studies.

The "LACE" (Length of stay, Acuity of admission, Co-morbidities, Emergency department visits in previous six months) Index
Access the tool in online, PDF, or Word formats. Developed to predict the risk of death or unplanned readmission within 30 days after discharge from hospital to the community, the impact of using the LACE Index was first published in 2010.

BOOST "8P" Screening Tool
This tool takes into account eight factors (Problem with medications, Psychological, Principal diagnosis, Physical limitations, Poor health literacy, Poor patient support, Prior hospitalization, Palliative care) that can be mitigated through intervention.

Fundamentals of Reducing Acute Care Hospitalization
Developed specifically for home health agencies, this tool is a component of a larger Best Practice Improvement Package.

Communication Standards

Inter-Facility Infection Control Patient Transfer Form
Review this sample form, distributed by the CDC, to compare the data your facility sends when a patient transfers to another setting. Are you including all the relevant information to control and prevent infections?

Tips for Obtaining a Best Possible Medication History (see the Preventing Adverse Drug Events section, below)

Improving communication is a crucial component of Project RED (Re-Engineered Discharge) and Project BOOST (Better Outcomes for Older Adults through Safe Transitions) as well as an important consideration in addressing racial disparities.

Standardizing the Problem List in the Ambulatory Electronic Health Record to Improve Patient Care
Maintaining an up-to-date problem list is essential to providing better individual patient care across multiple care sites.

Educating Patients & Their Families

Use Teach Back to increase patient comprehension and decrease risks during care transitions.

How does your community coalition incorporate the needs and wisdom of family caregivers? (Monthly Briefing, June 2017)
Learn about the four-part action plan developed by the Idaho Caregiver Alliance.

Get Started Implementing the Care Transitions Intervention® in Your Community: A Tool Kit for Washington State’s Area Agencies on Aging
Learn how to implement a community-based coaching program.

Use our "Going Home from the Hospital" video or our "Know Before You Go" presentation outline to help educate patients and families about preventing an avoidable readmission.

Distribute personal medication lists to patients. There's no need to recreate the wheel as many organizations have already developed effective versions. (See examples.)

Are you unsure about how to communicate with patients regarding end-of-life goals? Clear communication not only helps prevent unnecessary hospitalizations, but it also can improve quality of care, increase peace of mind, and lower healthcare expenditures. See these resources for advice.

As part of Medicare Part B, providers may submit claims for the first 30 minutes of advanced care planning (CPT 99497) and for each additional 30 minutes of time spent in these discussions (CPT 99498).

Integrating Behavioral Health into Care Transitions


See our collection of resources related to caring for individuals with dementia.

Recommended Actions for Improved Care Transitions: Mental Illnesses and/or Substance Use Disorders
Produced by Minnesota's RARE Campaign, this publication provides recommendations in five areas essential to improving care transitions for populations with mental health conditions. It also identifies key recommendations that are important specifically for care transitions improvement when working with patients with new or existing mental illnesses. It does not specifically focus on delirium or dementia, but many of the recommendations will also help support these patients and their families.

Assessments, Toolkits, and Training Archive from the RARE Collaborative: Mental Health Care Transitions
This 2014-2015 Collaborative based in Minnesota focused on interventions and tools to help improve the safety of care transitions for patients with mental health issues.

Care Transition Interventions to Reduce Psychiatric Rehospitalization
Producted by the National Association of State Mental Health Program Directors, this publication outlines best practices for continuity of care, from state hospitals into the community.

Case Studies of Successful Behavioral Health Integration in Care Transitions
Provides highlights of successful alliances created as part of the Robert Wood Johnson Aligning Forces for Quality initiative. 

Bringing Behavioral Health into the Care Continuum: Opportunities to Improve Quality, Costs and Outcomes
Although this article by the American Hospital Association was written several years ago (2012), it still provides a useful big-picture view of the opportunity gaps that still persist regarding cross-setting care for patients with mental illnesses.

Interventions Specifically Designed for Long-Term Care Settings

INTERACT (Interventions to Reduce Acute Care Transfers) is a quality improvement program designed to improve the early identification, assessment, documentation, and communication about changes in the status of residents in skilled nursing facilities.

Discharge Preparation Checklist
Adapted from ProjectRED for Qualis Health's Home to Stay Collaborative, this resource can help you redesign workflows to ensure that best practices are followed more consistently.

Interventions Specifically Designed for Patients Experiencing Homelessness

Our new initiative, Caring Beyond Healthcare, will be developing and distributing resources related to social determinants of health, such as homelessness.

Toolkit: Medical Respite Care for the Homeless
Learn about medical respite services that allow homeless individuals the opportunity to rest in a safe environment while accessing medical care and other supportive services. Medical respite care is offered in a variety of settings including freestanding facilities, homeless shelters, nursing homes, and transitional housing.

Hospital to Home Initiative
Read about the study design and ongoing impacts of this community-based intervention for low-resource homeless individuals with complex health care needs. It was designed, in part, to provide healthcare and support services to reduce excess hospitalizations and ED use among the homeless population.

Preventing Adverse Drug Events


Use this checklist to gauge the additional risk of falls when considering prescribing opioids to patients.


Nursing homes: Download this anticoagulation therapy Situation-Background-Assessment-Request (SBAR) form to communicate patient changes to your facility's physician.

Anticoagulants, opioids, and insulin are three of the most commonly implicated medications in ADEs. In fact, one study found that over half of emergent ADE-related hospitalizations of older Americans involved warfarin and hypoglycemics.

Are you partnering with the pharmacists in your community? (Monthly Briefing, September 2017)
Learn how pharmacists can help improve drug adherence and prevent the over- or under-use of medications for patients with multiple prescriptions.

Pharmacy students screen for ADEs (Monthly Briefing, January 2017)
Learn about this innovative program at the Idaho State University College of Pharmacy.

Take this video-based course about reducing hypoglycemic adverse drug events and earn free continuing education credits.  


Medication Reconciliation

Leaving Med Wreck in the Dust
March 2016 webinar
Join us as a local hospital shares lessons from the recent redesign of their medication reconciliation system.

Medication Reconciliation in Transitions of Care
June 2015 webinar
Join us for an "all teach, all learn" webinar as we use the MARQUIS Medication Reconciliation Implementation Manual (see below) to critically reflect on the process of medication reconciliation. The learning objectives of this webinar include: 1.Identify the key steps in medication reconciliation 2.Explore how MARQUIS applies to your population/setting 3.Make the business case for medication reconciliation

document thumbnailTips for Obtaining a Best Possible Medication History
A handout for our June 2015 webinar. Provides several straightforward tips for getting the most comprehensive and accurate medication history from patients.


In-home visits from pharmacist helped reduce readmission rates
(Monthly Briefing, April 2017)
Read how a Seattle hospital and community pharmacy group partnered to provide follow-up services to patients (including medication reconciliation) and reduce rehospitalizations.

Pocket Card: How to Conduct a Best Possible Medication History
MARQUIS' handy summary for eliciting a complete medication history from patients.

Consider also supplying patients with their own personal medication lists.

Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) Medication Reconciliation Implementation Manual
Note: To download the manual, MARQUIS requires readers to complete a brief terms of use form.
The goal of MARQUIS is to develop better ways for medications to be prescribed, documented, and reconciled accurately and safely when patients transition into and out of the hospital. This is a comprehensive, 200-page manual.

Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation
Medication reconciliation is a complex process that impacts all patients as they move through all healthcare settings. Implementation of an effective process can detect and avert most medication discrepancies, potentially avoiding a large number of adverse drug events.

(Also see the "Educating Patients & Their Families section, above, for resources related to information transfer with patients.)

High-Alert Medications and High-Risk Patients

CDC Guideline for Prescribing Opioids for Chronic Pain
Published in March 2016, the CDC guideline provides recommendations about the appropriate prescribing of opioid pain relievers and other treatment options to improve pain management and patient safety. Download the guideline and the prescribing checklist, and get other related resources.

University of Washington Pain and Opioid Consult Hotline for Clinicians
Clinicians located in Washington who are treating patients with complex pain medication regimens can get free consultations with UW pain specialists.

How-to Guide: Prevent Harm from High-Alert Medications
Note: To access this report, the Institute for Healthcare Improvement requires readers to log in. (Registration is free.)
The guide includes evidence-based methods to prevent, identify, and mitigate harm from high-alert medications, as well as ideas for tracking progress toward improvement.
Notes from our pharmacist consultant, Diane Schultz, RPh CPPS
"I appreciate the general strategies offered in this guide, the encouragement for taking one small step at a time, and the focus on change concepts that promote partnerships with patients and their families."

National Action Plan for Adverse Drug Event Prevention
Describes key actions to improve safety and reduce patient harm within three high-alert medication classes (anticoagulants, diabetes agents, and opioids), with an emphasis on aligning efforts across all care settings.
Notes from our pharmacist consultant, Diane Schultz, RPh CPPS
"Don't let the length of this action plan overwhelm you; it is a rich resource. Picking one drug class would be a great way to begin (see the Opportunities for Advancing ADE Prevention charts at the end of each medication section)."


Prescription Monitoring Programs
A recent study found that nearly a third of local Medicare beneficiaries who are chronic users of opioid medications actually had more than 365 days of opioid prescriptions in the calendar year.  Prescription Monitoring Programs exist in every state to alert healthcare providers to the potential of overprescribing. Providers should be sure to register for the Idaho or Washington program.

Use these interventions to prevent adverse drug events
Read the article, originally published in the April 2015 edition our Monthly Briefing.

A focus on ADEs can help reduce rehospitalizations
Read the article, originally published in the January 2015 edition our Monthly Briefing.

Managing Change

Community Assessment Form
As your community comes together to improve transitions and coordination of care, it is important to evaluate the current situation. Seek perspectives from multiple settings (including emergency medical service providers). What is working well? Where could improvements be made? Use our Community Assessment Form to guide your discussion.

Performing an informal assessment (or a more rigorous root cause analysis or current-state mapping) will help your coalition reach consensus on where to focus your effort in the near future.

Change can be challenging, regardless of whether you are working with a two-person team or an entire community of stakeholders. Read about some of the strategies and methodologies proven to work across a variety of situations.

Penalties, Incentives & Billing

Transition Care Management in the Clinic Setting— Update on Payment Programs
October 2014 webinar
Has your practice been successful in implementing the CPT codes that Medicare introduced to cover Transitional Care Management (TCM) services? In this webinar, learn how your peers have been using the TCM codes, how to overcome common coding challenges, and how to put into place recommended practices for providing safer, higher quality care for your patients during these critical junctures. Join us as we review the use of both TCM codes and Chronic Care Management coding for Medicare and private insurers.

To reduce readmissions, Medicare is expanding incentives and penalties
May 2014 update, focused on issues pertinent to hospitals and skilled nursing facilities.

Quality Improvement Planning & Measurement

New! Care Transitions Assessment
Use our 33-element assessment to identify opportunities for improvement in your hospital's processes related to care transitions and discharging patients.

Selecting and Sustaining Improvement Activities
November 2015 webinar hosted by Qualis Health
We get data and information from a variety of sources—and then we need to identify what it all means in terms of improvement possibilities, what will give us the change we want, and how we can keep it going. Join us to learn how to move from needs identification, to designing and implementing activities that will bridge those gaps, to sustaining forward movement.

Review and Interpretation of Community Performance Reports
March 2015 webinar hosted by Qualis Health
Do you know whether your interventions are changing your community's rehospitalization rate? Are you sure the change is moving in the desired direction? Join us in this webinar as we take a deep dive into the Community Performance Reports produced by Qualis Health each quarter. We will walk through the report and discuss how to interpret and make best use of the data. (Be sure to review your community's report prior to the webinar.)

The better your interventions are planned and monitored, the more likely their success. For guidance, see:

Aim statements and Plan-Do-Study-Act (PDSA) cycles

Run charts


Other Resources

Are paramedics part of your community's care transition coalition?
Read the article, originally published in the March 2015 edition our Monthly Briefing.

Webinar Archive

Did you miss one of the Communities for Safer Transitions of Care webinars? The slides and session recordings are available for the following selected events:

Sepsis Management Across the Care Continuum
View archive

November 17, 2016


Honoring Choices
View archive

May 19, 2016


Leaving Med Wreck in the Dust
View archive

March 17, 2016


CJR: Program Overview and Cost Analyses for Washington Hospitals
View archive

February 3, 2016

Selecting and Sustaining Improvement Activities
View archive

November 19, 2015


Disparities, Superutilizers and New Approaches for Health Equity
View archive

September 17, 2015


Medication Reconciliation in Transitions of Care
View archive

June 18, 2015


Review and Interpretation of Community Performance Reports
View archive

March 19, 2015


Taking the Next Steps in Improving Care Transitions
View archive

January 20, 2015

Transition Care Management in the Clinic Setting—
Update on Payment Programs
View archive

October 8, 2014