IMPROVE. HEALTHCARE. FASTER.

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!

Do you have any resources that could be helpful for the community? Let us know.

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Examples of interventions involving community care settings to reduce re-hospitalizations.
Title & Description Author Date Type
Atlanta Care Transitions Initiative
ARC Webinar
Cathie Berger 08/17/11
(pdf)
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Collaborating with Community Partners
Presentation from "Beyond Hospital Walls: Strategies for Reducing Readmissions"
Yvonne Chan & Susan Houston 04/24/13
(pdf)
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Eddy VNA Transitional Care Program
ARC Webinar (The New York Experience)
Susan O'Bryan 07/13/11
(pdf)
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Improving Care Transitions in Northwest Denver
Risa Hayes 02/23/12
(pdf)
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Involving Community in Reducing Readmissions
ARC Webinar
Nancy Vecchio 11/16/11
(pdf)
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Managing the Million Dollar Men and Women: The Humboldt County Experience
Tory Starr 12/04/12
(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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Best Practices in Ambulatory Care
Presentation from "Beyond Hospital Walls: Strategies for Reducing Readmissions"
Steve Escamilla, Lance Lang & Samantha Valcourt 04/24/13
(pdf)
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Community Approach to Reducing Readmissions
Anya Vines 10/14/11
(pdf)
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Early Learnings from CCTP
Terry Winter 12/04/12
(pdf)
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Catching Discharged Patients in the Outpatient Setting
Ricki Stajer, RN, MA, CPHQ & Sarah Delgado, RN, MSN, ACNP 10/10/13
(pdf)
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Getting on the Same Page: Hospital, Community, Caregiver Alliance
Carol Levine 10/10/13
(pdf)
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Together We're Better: Extending Patient Care Outside the Hospital Walls
Partners in Care Foundation
June Simmons, MSW 10/10/13
(pdf)
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Together We're Better: Extending Patient Care Outside the Hospital Walls
Glendale Memorial Hospital and Health Center
Nancy Seck, RN, BSN, MPH, CPHQ 10/10/13
(pdf)
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Medical-Surgical Lower Level of Care (LLOC) Collaborative
Medical-Surgical Lower Level of Care (LLOC) Collaborative
Joan Spicer 09/24/14
(pdf)
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Reaching Outside the Hospital to Create Community Partnerships
Marcia Colone, Ph.D., MS, LCSW, ACM 09/30/15
(ppt)
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Building Community Backbone Support and Infrastructure for Sustainability
Marisue Garganta, Director of Community Health Integration and Community Benefit 09/28/15
(ppt)
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Kern County Care Coordination: A Collaborative Journey
Michael Smith, RN, MSN Ed, PHN 09/28/15
(pptx)
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Congregational Health Network
Memphis Model Adaptation Seminar
Joy D.Sharp, Lead Community Health Navigator Methodist Healthcare 09/28/15
(ppt)
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Collective Impact
FSG - Keynote Presentation
Mark Kramer JD, MBA and Abigail Stevenson MBA, MPH 10/15/15
(pdf)
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South County Health
Washington County Coalition established 1/2011
Lynne Driscoll RN, CCM,CPHM 09/28/15
(pptx)
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Medication Management: Community and Hospital Driven Pharmacy Interventions
UCSF School of Pharmacy
Marilyn Stebbins, PharmD 05/06/14
(pdf)
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Medication Management: Community and Hospital Driven Pharmacy Interventions
Evaluation of a Pharmacist-Led Bedside Medication Delivery Service for Cardiology Patients at Hospital Discharge
Julianna Burton, PharmD BCPS BCACP FCSHP & Stephanie Roberts, PharmD BCPS 05/06/14
(pdf)
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Collaborating with Community Pharmacies to Reduce Readmissions
Safeway Pharmacy
Brian Hille, BPharm 10/10/13
(pdf)
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Collaborating with Community Pharmacies to Reduce Readmissions
Ralphs Pharmacy
Lord Sarino, PharmD 10/10/13
(pdf)
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Collaborating with Community Pharmacies to Reduce Readmissions
Walgreens
Duane Hanson & Ed Cohen, PharmD, FAPhA 10/10/13
(pdf)
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It Takes a Village: How One ACO Has Partnered with Hospitals and Community Pharmacists to Improve Care Transitions
Brian Hodgkins, PharmD, FCSHP, FASHP & Tim Perlick, PharmD, CGP 10/10/13
(pdf)
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New Approaches to Community Pharmacist Interaction
Kevin Rodondi, PharmD & Marilyn Stebbins, PharmD 10/10/13
(pdf)
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Title & Description Author Date Type
Home Health and Readmissions
Bronwyn Calkins 10/14/11
(pdf)
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Learnings from a Local Expert
Celeste Chavez 01/19/11
(pdf)
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Seven Home-Health Touch Points to Prevent Avoidable Readmissions
Home Health Learning Session
Jennifer Wieckowski 09/19/13
(pptx)
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Home Health Partnership
Home Health Learning Session
Dorothy Coffey 09/19/13
(pptx)
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Our ARC Journey…Professional Home Care Associates
Home Health Learning Session
Cheryl Haynes 09/19/13
(ppt)
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Cedars-Sinai Health System: Partnering with Home Health Agencies and Nursing Homes to Prevent Hospital Readmissions
Katie Gurvitz, MHA, Kelley Hart, LVN & Michelle Hofhine, RN 10/10/13
(pdf)
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Title & Description Author Date Type
Improving Geriatric Care by Decreasing Potentially Avoidable Hospitalizations
Joseph Ouslander 04/20/11
(pdf)
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SNF-Hospital Collaboration: Antioch & Lone Tree Convalescent
Presentation from "Beyond Hospital Walls: Strategies for Reducing Readmissions"
Phylene Sunga 04/24/13
(pdf)
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Community SNU/ECF Transfer Checklist
Transfer Checklist
06/11/13
(xlsx)
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Emergency Transfers of the Elderly from Nursing Facilities to Critical Access Hospitals
Nursing Home Transfers
Flex Monitoring Team 06/11/13
(pdf)
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Nursing Home Capabilities List
Skilled Nursing Facility
Interact 3.0 04/07/14
(pdf)
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AC2SNF: Acute Care to Skilled Nursing Facility Efforts to Reduce Readmissions in Santa Clara County
Acute Care to Skilled Nursing Facility (AC2SNF) Planning Collaborative
Jo Coffaro, Steve Church, & Siva Subramanian 05/06/14
(pdf)
View/Download

Title & Description Author Date Type
Referring Patients and Family Caregivers to Community-Based Services: A Provider’s Guide
Patient and Family Engagement
Next Step In Care 07/19/13
(pdf)
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Bay Area Community Resource Guide
08/28/14
(pdf)
View/Download