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Tools & Resources

Here you will find tools and resources including presentations and materials from our webinars, in-person meetings and others that we have vetted and believe will be valuable to you!

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Multi-disciplinary tools to support care transition efforts.
Title & Description Author Date Type
ARC Webinar - Intermountain Risk Score-Heart Failure and Myocardial Infarction Tool (IMRS-HF and IMRS-MI)
Predicting risk of readmission with IMRS-HF and IMRS-MI tools.
Benjamin D. Horne, PhD, MPH, FACC, FAHA 07/10/13
(pdf)
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Best Practice Intervention Practice
Acute Care Hospitalization
Home Health Quality Improvement 03/05/14
(pdf)
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Preventable Readmissions Top 10 Checklist - 2016 Update
AHA/HRET HEN 2.0 02/17/17
(pdf)
View/Download

Title & Description Author Date Type
ARC Webinar - The Conversation Project: National Perspective and Local Implementation
Helping people talk about their wishes for end-of-life care.
Marilyn Ababio & Mandy Ferguson 03/05/14
(pdf)
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POLST Procedure Update-2015
Vincent Nguyen 04/06/15
(pdf)
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FINDING the HEART in Advance Care Planning & End of Life Discussions
Advancing Advance Care Planning
Marilyn Ababio 02/05/15
(pdf)
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Title & Description Author Date Type
ARC Webinar - Implementation of Physician Orders for Life Sustaining Treatment (POLST)
Approach to end-of-life planning that emphasizes patient wishes.
Dr. Jeff Yee & Dr. Vincent Nguyen 04/03/13
(pdf)
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ARC Webinar - Palliatative Care in the Emergency Department
Emergency Physician model for providing Palliative Care.
Travis E. DeVader, MD 05/01/13
(pdf)
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Comparisons between palliative care consultation services in California hospitals from 2007 to 2011
Palliative Care Survey UCSF
Dr. David O'Riordan 02/13/13
(pdf)
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Palliative Care in Readmission Reduction
Steve Pantilat MD 10/14/11
(pdf)
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Palliative Care Webinar
Palliative Care
Partnership for PAtients 06/11/13
(pdf)
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Sharp HospiceCareís: A New Model for Late Stage Disease Management
Sharp HospiceCare
Dr. Daniel Hoefer and Suzi Johnson 02/13/13
(pdf)
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KPNC Life Care Planning based on Respec6ng Choices
Scott Keech and Melissa Stern 02/05/15
(pdf)
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Title & Description Author Date Type
Resource from Chinese Hospital-please give credit if you use
Chinese Hospital 04/13/11
(pdf)
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Reducing Hospital Readmissions With Enhanced Patient Education
Patient Education
06/11/13
(pdf)
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Improving Patient Education
Janet Grace, RN, BSN Saline Memorial Hospital 06/11/13
(ppt)
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Title & Description Author Date Type
Nurse Navigator -ACMC
Nancy Halloran and Inger Harris 08/09/11
(pdf)
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Comprehensive Discharge Planning and Home Follow-up of Hospitalized Elders
Mary Naylor et.al. 04/21/11
(pdf)
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Comprehensive Discharge Planning for the Hospitalized Elderly
Mary Naylor 04/21/94
(pdf)
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Discharge Follow-up Phone Call
Discharge Follow-up Phone Call
06/11/13
(docx)
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Discharge TIme Out
Discharge
06/11/13
(docx)
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Purple Discharge Folder
Discharge
06/11/13
(doc)
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Purple Discharge Folder Label
Discharge Folder
06/11/13
(doc)
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Protocol for Post Hospitalization Intervention Phone Call
San Francisco General Hospital 08/18/13
(pdf)
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Discharge SFGH Transitional Care Program with Risk
San Francisco General Hospital 08/18/13
(pdf)
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ARC Webinar - Leveraging Mobile Care Coordination Technology To Reduce Readmissions
CareInSync's collaboration with Marin General Hospital to build the nation's first 'Mobile Care Transitions Network'.
Susan Cumming, MD & Siva Subramanian, PhD 09/04/13
(pdf)
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Nursing Home Capabilities List
Skilled Nursing Facility
Interact 3.0 04/07/14
(pdf)
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ARC Webinar - Grand-Aides USA
Learn about the Grand-Aides program, an innovative post discharge workforce model that delivers personalized care at lower cost and prevents unnecessary hospital readmissions.
Arthur Garson, Jr., MD, MPH 05/14/14
(pdf)
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Title & Description Author Date Type
Documenting and Doing
Dionette Kelton 02/23/12
(pdf)
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In the Act- Teach Back
David Renfro 02/23/12
(pdf)
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Support from Hospital to Home for Elders
Jeff Critchfield, Richard Santana and Diane Robbins 06/08/11
(pdf)
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Teaching Teach Back
Staci Valdix 01/19/11
(pdf)
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Health Literacy and use of Teach-Back for patient education
Teach back
06/11/13
(pdf)
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10 Elements of Competence for Using Teach-back Effectively
Teach Back
06/11/13
(pdf)
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Staff Competency Validation for Teach Back
Teach Back
Missouri Hospital Engagement Network 06/11/13
(pptx)
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Teach-back: A Health Literacy Tool to Ensure Patient Understanding
Teach Back
The Iowa Health System Health Literacy Collaborative 06/11/13
(ppt)
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Resident Tool Kit: Teach Back
Teach Back
06/21/13
(pdf)
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Teach Back Questions - CHF
Assessment and Implementation Tools
Baptist Health Madisonville 09/23/13
(doc)
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Teach Back Questions - Stroke
Assessment and Implementation Tools
Baptist Health Madisonville 09/23/13
(doc)
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Title & Description Author Date Type
Community Approach to Reducing Readmissions
Anya Vines 10/14/11
(pdf)
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Reducing Preventable Readmissions-A guide for Nurses
ACMC Fact Sheet
ACMC 01/11/12
(doc)
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Reducing Preventable Readmissions-A guide for Pharmacists
ACMC Fact Sheet
ACMC 01/11/12
(doc)
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Reducing Preventable Readmissions-A guide for Physicians
ACMC Fact Sheet
ACMC 01/11/12
(doc)
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Reducing Preventable Readmissions-A guide for Social Workers
ACMC Fact Sheet
ACMC 01/11/12
(doc)
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Sample Report
Sample Report
Pat Teske 09/13/11
(xls)
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Referring Patients and Family Caregivers to Community-Based Services: A Providerís Guide
Patient and Family Engagement
Next Step In Care 07/19/13
(pdf)
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Acute Care Hospital Utilization
Substance Use Disorders
Alexander Walley, et al. 07/31/13
(pdf)
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Title & Description Author Date Type
Health Literacy
Jennifer Pearce 10/14/11
(pdf)
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Motivational Interviews
Mindy Boccio 06/08/11
(pdf)
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Partnerships with Patients and Families
Jim Conway 06/08/11
(pdf)
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Patient Activation Measure
ARC Webinar
Chris Delaney 12/15/10
(pdf)
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Patient and Family Centered Care
Jenny Buchanan 06/08/11
(pdf)
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Perfecting Patient Care Experience in Care Transitions
Teresa Childers 02/23/12
(pdf)
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Patient Engagement Through Health Literate Care
Presentation from "Beyond Hospital Walls: Strategies for Reducing Readmissions"
Jennifer Pearce 04/24/13
(pdf)
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Top Ten Things You Need to Know About Engaging Patients
Institute For Health Technology 04/01/11
(pdf)
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Health Literacy Universal Precautions Kit
Health Literacy
AHRQ 06/11/13
(pdf)
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Health Literacy Universal Precautions Kit
Health Literacy
AHRQ 06/11/13
(pdf)
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RI Hospital ICU Patient Brochure
Patient Activation
RI Hospital 06/11/13
(pdf)
View/Download
ARC Webinar - Patient and Family Engagement: Recruiting for Patient Family Advisory Councils & A Review of Engagement Tools
Libby Hoy & Julia Hallisy, DDS 01/08/14
(pptx)
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Always Events® Getting Started Kit
Patient and Family Engagement
IHI 03/21/14
(pdf)
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Empowered Patient Hospital Guide for Patients and Families
Julia Hallisy 06/14/15
(pdf)
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Title & Description Author Date Type
LACE Tool
Ron Krielkamp 08/09/11
(pdf)
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Readmission Formula
Formula
Pat Kearns, MD 10/12/11
(doc)
View/Download
RI Hospital Communication Bundle
Individual Quality Measurement Gap Analysis Data Collection Tool Kit
RI Hospital 06/11/13
(doc)
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The Communication Bundle Quality Measures
Modules
06/11/13
(pdf)
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RI Hospital Communication Bundle 2
Quality Measures
06/11/13
(doc)
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Risk Assessment Formula
Formula
Pat Kearns, MD 10/12/11
(doc)
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Peninsula Circle of Care Readmit Interview Form
Risk Assessment
Peninsula Circle of Care 04/07/14
(pdf)
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Peninsula Circle of Care Risk for Readmission Tool
Risk Assessment
Peninsula Circle of Care 04/07/14
(pdf)
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Standard Work for ED Notification for Potential Project Re-Engineering Discharge (RED) Patients
Eric Gillens 03/16/15
(pdf)
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