Readmissions and Transitions of Care
Prevention Strategies Gap Analysis
Yes
Gap Analysis Questions
No
Just
Starting
Initiative Oversight
Senior Leadership has identified a physician champion(s)
and/or senior executive for improving transitions and
reducing readmissions.
Senior Leadership has identified an operational champion(s)
improving transitions and reducing readmissions (e.g. Case
management Director, Social Worker, Nursing Leader).
The facility has a process in place to partner the physician
and operational champions for improving transitions and
reducing readmissions.
Senior Leadership has defined roles, set expectations and
provides support for the champion(s) of improving
transitions and reducing readmissions.
The facility adopts a team approach to improving transitions
and reducing readmissions with an interdisciplinary team to
oversee and support the work.
The facility has a cross-functional team that meets regularly
to assess the current state of care transitions, and are
empowered to take action if deficits are found.
The facility has a designated coordinator to oversee
implementation of chosen strategies (e.g. schedule team
meetings, plan staff education)
Individual roles for team members are clearly defined.
Stakeholder representation on team includes all transition
settings including primary care, long-term care and home
health, etc.
Hospital Specific:
___________________________________________
___________________________________________
Acknowledgement: Adapted from the Minnesota
Hospital Association Patient Safety Roadmap, used with permission
If answered question “NO” –
or just starting, indicate the
priority, person responsible
and target and
implementation date.
Inpatient Care Transition
Processes
Yes
No
Just
Starting
The facility has a process for review of records for patients
readmitted for any gaps in care, or preventable harms.
The facility has developed standard criteria for readmissions
chart auditors.
Senior leadership has set clear expectations for effective
completion of the discharge process prior to any transition.
Upon admission, patients are assessed for their risk of
readmission.
The facility gathers contact information for any persons
designated as the patient’s caregiver post-discharge.
The facility has a process in place to audit readmissions for
gaps in care or preventable harms.
A standardized process is in place for post-discharge followup calls.
Patients discharged from the facility receive a follow-up
phone call within 72 hours of discharge
Patients scheduled for follow-up care after discharge leave
the hospital with appointment dates and times.
Patients have an accurate medication list, which is
reconciled by a pharmacist or nurse, prior to discharge.
Pharmacists are available for consultations with patients and
family members prior to discharge.
Using Teach Back, patients are able to articulate their
warning signs and when to contact a physician once they
are discharged.
Documentation of patient teaching includes what the patient
knows about their condition, self-care, medications – not
only what they were taught.
The patient’s caregiver is present for discharge instructions.
Hospital Specific:
___________________________________________
___________________________________________
Acknowledgement: Adapted from the Minnesota
Hospital Association Patient Safety Roadmap, used with permission
If answered question “NO” –
or just starting, indicate the
priority, person responsible
and target and
implementation date.
Outpatient Care Transition
Processes
Yes
No
Just
Starting
Senior leadership has set clear expectations for effective
completion of a safe transition of their patients from the
hospital to any other setting.
Hospital documentation of the care plan at discharge is
forwarded to the next site of care within 24 hours of the
patients discharge.
The facility works with primary care offices to ensure
patients with scheduled follow-up phone calls are seen in
the ambulatory setting; and if no-show, there is follow-up.
The facility tracks the recently discharged patients that
return to the ED, assess the reasons for return and design
processes to prevent this from occurring.
The facility has a standard set of information that is
transferred to long-term care facilities upon the patients
discharge to those setting.
Patients deemed to be at extremely high risk for
readmission have an ambulatory appointment within 48-72
hours of discharge.
Patients deemed to be at extremely high risk for
readmission have a “warm hand-off” between the hospital
staff and the clinic staff.
Patients with chronic conditions (CHF, COPD, Diabetes)
that are at high risk for readmission have been identified for
closer monitoring in the outpatient setting.
The facility participates in a community transitions of care
coalition, or convenes meetings regularly with local care
providers to determine if there are gaps in transitions.
The facility works closely with the local Aging and Disability
Resource Center, and other local organizations, to help
close gaps in care transitions that may be present locally.
Hospital Specific:
___________________________________________
___________________________________________
___________________________________________
___________________________________________
Acknowledgement: Adapted from the Minnesota
Hospital Association Patient Safety Roadmap, used with permission
If answered question “NO” –
or just starting, indicate the
priority, person responsible
and target and
implementation date.
Educate staff and patients
Yes
No
Just
Starting
If answered question “NO” –
or just starting, indicate the
priority, person responsible
and target and
implementation date.
Yes
No
Just
Starting
If answered question “NO” –
or just starting, indicate the
priority, person responsible
and target and
implementation date.
Expectations and supporting education have been
incorporated into orientation for new physicians and other
practitioners involved in care transitions.
Staff education on improving transitions and reducing
readmissions is provided at least annually.
Patient/family safe transition education tools are
disseminated as appropriate upon admission and discharge
Teach Back is used consistently as part of patient teaching.
Patients’ ability to recall warning signs and who to call if
there is a problem after discharge is documented as part of
teaching.
Hospital Specific:
___________________________________________
___________________________________________
Data Collection and Monitoring
The facility has a process in place to review and analyze
data on a regular basis for learning and improvement
opportunities related to improving transitions and reducing
readmissions
Data is shared within and across teams at least monthly
Data is shared with senior leadership at least quarterly
Data is shared with the facility’s medical staff at least
quarterly
The facility collects HCAHPS measures related to patient
transitions of care, and reviews the data regularly.
The facility tracks metrics across different care settings:
hospital to primary care, hospital to long-term care, ED
returns after hospitalization, etc.
Hospital Specific:
___________________________________________
Documentation
Acknowledgement: Adapted from the Minnesota
Hospital Association Patient Safety Roadmap, used with permission