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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!

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

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Title & Description Author Date Type
Reducing Readmissions Change Package
HRET-Cynosure 04/30/15
(pdf)
View/Download
Reducing Readmissions Checklist
HRET-Cynosure 04/30/15
(pdf)
View/Download
Community Collaboration - Care Transitions Webinar, Sept. 2, 2015
Presentation by Carrie Wong, Lindsay Holland & Pat Teske
Cynosure Health 09/02/15
(pptx)
View/Download
CommUNITY Collaboration to Reduce Readmissions Guide
A guide to support those interested in developing or strengthening the work in their communities
Pat Teske, RN, MHA, ARC/Cynosure Health 09/18/15
(pdf)
View/Download
Community Collaboration - Care Transitions Webinar, Sept. 2, 2015 ppt
Presentation file for the Community Collaboration Care Transitions Webinar (9/2/15)
ARC/Cynosure Health 09/02/15
(pptx)
View/Download
Huddle for Care Flyer
Huddle for Care is an interactive website and mobile application for story sharing among care transition innovators and implementers.
Huddle for Care 01/11/16
(pdf)
View/Download
Bay Area Resource Guide
Bay Area Resource Guide
01/12/16
(pdf)
View/Download
Reducing Readmissions-2015 Focus on Medicaid, the Emergency Department and Behavioral Health
Amy Boutwell, MD 02/25/15
(pdf)
View/Download
Readmissions Management: It Takes a Village
Spring Readmission Summit
Dr. Michael Langberg 06/30/14
(pdf)
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The Path Ahead: Choosing to Use the Most Powerful Model in the World
Dennis Wagner, MPA 05/06/14
(pdf)
View/Download
Bridging Medicine, Patients, and Community-Based Services Together to Reduce Readmissions
San Francisco Transitional Care Program
Mary Ann Calles, RN BSN MSN-c, Melinda Mata, RN MSN MBA, & Carrie Wong, MSW MPH LCSW 05/06/14
(pdf)
View/Download
Sustaining Your Gains Year After Year
Avoiding Readmissions, Sustaining the Gains
Richard L. Fraioli, MD & Terri Jagow, RN 05/06/14
(pdf)
View/Download
The Best of Dignity: Innovative Tools to Prevent Unnecessary Readmissions
Zenobia Collins Johnson, RN BSN MBA CPHIT CLNC, Erica Mares, RN BSN MBA CCM, & Kay Duncan, RN BSN MBA CPHQ CCM 05/06/14
(pdf)
View/Download
Navigating the Transition from Volume to Value
Bruce Spurlock, MD 02/16/15
(pdf)
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Impacting Hospital Readmissions PIH Health Cares Program Intensive Outpatient Care Program
Ricki Stajer 02/05/15
(pdf)
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Intensive Outpatient Care Program: Positive Impact on Readmissions
Karen R Vanaskie 02/05/15
(pdf)
View/Download
Reducing Readmission Rates
reducing readmissions rates
Robert Cherry, June Simmons, Dr. Sam Skootsky 02/16/15
(pdf)
View/Download
Many Roads Lead to the Top of the Mountain: Three Different Approaches to Reduce Readmissions
Eileen Brinker, RN, MSN, Valerie Cronin, LCSW & Shogofa Zamon 10/10/13
(pdf)
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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)
View/Download
Keynote Address - The Future Isn't What it Used to Be
Reducing Readmission Risk through High Quality Transitions
Jane Brock, MD, MSPH 10/10/13
(pdf)
View/Download
The Case for Staying the Course: Hospital Patient Safety Improvement Stories
Michele Davenport Lambert, RN, FNP, MBA, FACHE 10/10/13
(pdf)
View/Download
Preventable Readmissions, 2016 Update
Change Package
HRETHEN 02/19/17
(pdf)
View/Download

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)
View/Download
Best Practice Intervention Practice
Acute Care Hospitalization
Home Health Quality Improvement 03/05/14
(pdf)
View/Download
Preventable Readmissions Top 10 Checklist - 2016 Update
AHA/HRET HEN 2.0 02/17/17
(pdf)
View/Download

Materials on alignment methods to optimize transitions of care.
Title & Description Author Date Type
ACO Approach to Reducing Readmissions 1
Terri Scott 12/04/12
(pdf)
View/Download
ACO Approach to Reducing Readmissions 2
John Hirshliefer 12/04/12
(pdf)
View/Download
CARE Network
Presentation from "Beyond Hospital Walls: Strategies for Reducing Readmissions"
Dana Codron & Aura Silva 04/24/13
(pdf)
View/Download
Care Transitions at Stanford Coordinated Care
Presentation from "Beyond Hospital Walls: Strategies for Reducing Readmissions"
Samantha Valcourt 04/24/13
(pdf)
View/Download
Center for Care Innovations
Presentation from "Beyond Hospital Walls: Strategies for Reducing Readmissions"
Veenu Aulakh 04/24/13
(pdf)
View/Download
Engaging Hospitalists to Improve Care Transitions
Michael Weiss, MD 02/23/12
(pdf)
View/Download
Health Plans and Medical Groups approaches to readmission reduction
Barsum Kasravi, MD, MPH 01/19/11
(pdf)
View/Download
HealthCare Partners Best Practices
Stuart Levine MD 10/14/11
(pdf)
View/Download
Glens Falls Hospital Care Transitions
ARC Webinar (The New York Experience)
Christine Freire 07/13/11
(pdf)
View/Download
Implementing the Bridge Model to Reduce Readmissions at a Major Medical Center
Walter Rosenberg, MSW 10/10/13
(pdf)
View/Download
Good to Go: Using Technology to Improve Care Transitions
Cheryl Bailey, RN, BSN, MBA 10/10/13
(pdf)
View/Download
A Way to Approach Addiction in Your Readmission Reduction Efforts
Mark Stanford, PhD 10/10/13
(pdf)
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Improving Marketshare by Improving Value
Senior Leadership Dinner
Arnold Milstein MD and Kimberly Brayton MD, JD 04/22/14
(pptx)
View/Download
Strategies to reduce readmissions in safety net hospitals
Public Hospital Deep Dive
Amy Boutwell 07/07/14
(pdf)
View/Download
The San Diego Care Transitions Partnership
Transforming Care Across the Continuum
Brenda Schmitthenner, MPA 09/28/15
(pptx)
View/Download
Facilitating Safe and Meaningful Transitons of Care
Theresa Frei and Tory Starr 02/05/15
(pdf)
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Integrating Patients & Families as Advisors into our Care Transitons Work
Alice Gunderson and Mary Lynne Knighten 02/05/15
(pdf)
View/Download
Intensive Outpatient Care Program: Positive Impact on Readmissions
Karen R Vanaskie 02/05/15
(pdf)
View/Download
Engaging Front Line in Care Transitions
Peninsula Circle of Care- Engaging Front Line Nurses
Areena Chaudhry, RN, BSN, MPA 05/06/14
(pdf)
View/Download
Engaging Front Line in Care Transitions
St. Rose Hospital Project RED
Linda Aug & Shogofa Zamon 05/06/14
(pdf)
View/Download
Engaging Front Line in Care Transitions
St. Francis Medical Center- Engaging Front Line Staff in Readmission Reduction
Regina Truong, RN 05/06/14
(pdf)
View/Download
St. Jude Heritage Healthcare: Bridging Care from the Hospital to Your Doctor
Bridging Care from the Hospital Back to the PCP
Eleni Manousogiannakis, MPH 05/06/14
(pdf)
View/Download
Keynote Address - The Future Isn't What it Used to Be
Reducing Readmission Risk through High Quality Transitions
Jane Brock, MD, MSPH 10/10/13
(pdf)
View/Download
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)
View/Download
Catching Discharged Patients in the Outpatient Setting
Ricki Stajer, RN, MA, CPHQ & Sarah Delgado, RN, MSN, ACNP 10/10/13
(pdf)
View/Download

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)
View/Download
Collaborating with Community Partners
Presentation from "Beyond Hospital Walls: Strategies for Reducing Readmissions"
Yvonne Chan & Susan Houston 04/24/13
(pdf)
View/Download
Eddy VNA Transitional Care Program
ARC Webinar (The New York Experience)
Susan O'Bryan 07/13/11
(pdf)
View/Download
Improving Care Transitions in Northwest Denver
Risa Hayes 02/23/12
(pdf)
View/Download
Involving Community in Reducing Readmissions
ARC Webinar
Nancy Vecchio 11/16/11
(pdf)
View/Download
Managing the Million Dollar Men and Women: The Humboldt County Experience
Tory Starr 12/04/12
(pdf)
View/Download
Support from Hospital to Home for Elders
Jeff Critchfield, Richard Santana and Diane Robbins 06/08/11
(pdf)
View/Download
Best Practices in Ambulatory Care
Presentation from "Beyond Hospital Walls: Strategies for Reducing Readmissions"
Steve Escamilla, Lance Lang & Samantha Valcourt 04/24/13
(pdf)
View/Download
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)
View/Download
Catching Discharged Patients in the Outpatient Setting
Ricki Stajer, RN, MA, CPHQ & Sarah Delgado, RN, MSN, ACNP 10/10/13
(pdf)
View/Download
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)
View/Download
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)
View/Download
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)
View/Download
Building Community Backbone Support and Infrastructure for Sustainability
Marisue Garganta, Director of Community Health Integration and Community Benefit 09/28/15
(ppt)
View/Download
Kern County Care Coordination: A Collaborative Journey
Michael Smith, RN, MSN Ed, PHN 09/28/15
(pptx)
View/Download
Congregational Health Network
Memphis Model Adaptation Seminar
Joy D.Sharp, Lead Community Health Navigator Methodist Healthcare 09/28/15
(ppt)
View/Download
Collective Impact
FSG - Keynote Presentation
Mark Kramer JD, MBA and Abigail Stevenson MBA, MPH 10/15/15
(pdf)
View/Download
South County Health
Washington County Coalition established 1/2011
Lynne Driscoll RN, CCM,CPHM 09/28/15
(pptx)
View/Download
Medication Management: Community and Hospital Driven Pharmacy Interventions
UCSF School of Pharmacy
Marilyn Stebbins, PharmD 05/06/14
(pdf)
View/Download
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)
View/Download
Collaborating with Community Pharmacies to Reduce Readmissions
Safeway Pharmacy
Brian Hille, BPharm 10/10/13
(pdf)
View/Download
Collaborating with Community Pharmacies to Reduce Readmissions
Ralphs Pharmacy
Lord Sarino, PharmD 10/10/13
(pdf)
View/Download
Collaborating with Community Pharmacies to Reduce Readmissions
Walgreens
Duane Hanson & Ed Cohen, PharmD, FAPhA 10/10/13
(pdf)
View/Download
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)
View/Download
New Approaches to Community Pharmacist Interaction
Kevin Rodondi, PharmD & Marilyn Stebbins, PharmD 10/10/13
(pdf)
View/Download

Effective interventions to reduce re-hospitalizations.

Title & Description Author Date Type
Implementing the INTERACT II Toolkit
Laurie Herndon 04/20/11
(pdf)
View/Download
Nursing Home Capabilities List
Skilled Nursing Facility
Interact 3.0 04/07/14
(pdf)
View/Download
INTERACT Luncheon
CALTCM INTERACT III- Get Ahead of Readmissions!
Mary Gessay, CPHQ, ORSC 05/06/14
(pdf)
View/Download
INTERACT IV Overview
Jocelyn Montgomery 02/05/15
(pdf)
View/Download
INTERACT in Action Across Care Settings
Jocelyn Montgomery, Skelly Wingard and Terry Woodard 02/06/15
(pdf)
View/Download

Title & Description Author Date Type
Integrating Patients & Families as Advisors into our Care Transitons Work
Alice Gunderson and Mary Lynne Knighten 02/05/15
(pdf)
View/Download
KPNC Life Care Planning based on Respec6ng Choices
Scott Keech and Melissa Stern 02/05/15
(pdf)
View/Download
Accelerating Patient & Family Engagement
ARC's Patient Advisory Council: Year in Review 2013-2014
Lisa Ehle, MPH 05/06/14
(pdf)
View/Download
Accelerating Patient & Family Engagement
Lodi Health- Patient and Family Engagement
Valerie Cronin, LCSW 05/06/14
(pdf)
View/Download
Accelerating Patient & Family Engagement
Stanford Hospital and Clinics- Patient Engagement: Transforming Patient Care
Christine Thompson, MS RN CNS CCRN CHFN 05/06/14
(pdf)
View/Download
Bay Area Community Resource Guide
08/28/14
(pdf)
View/Download
Getting on the Same Page: Hospital, Community, Caregiver Alliance
Carol Levine 10/10/13
(pdf)
View/Download
Patient Engagement through Empowerment
Julia Hallisy, DDS 10/10/13
(pdf)
View/Download
Safety is Personal: Partnering with Patients and Families for the Safest Care
Patient and Family Engagement
National Patient and Safety Foundation 03/27/14
(pdf)
View/Download
Successful Strategies to Increase Patient Activation
Cheri Lattimer, RN, BSN 10/10/13
(pdf)
View/Download
Supporting Providers through Patient Centered, Interdisciplinary Palliative Care. Plus Insights into Outpatient Palliative Care Medicine
UMass Memorial Medical Center
Suzana Makowski, MD, MMM, FACP, FAAHPM 10/10/13
(pdf)
View/Download
Supporting Providers through Patient Centered, Interdisciplinary Palliative Care. Plus Insights into Outpatient Palliative Care Medicine
Palo Alto Medical Foundation
Sangeeta Kopardekar, MD 10/10/13
(pdf)
View/Download

Title & Description Author Date Type
Community Paramedicine: A Promising Model for Integrating Emergency and Primary Care
California Community Para-Medicine Report
Kenneth W. Kizer, MD, MPH; Karen Shore, PhD; Aimee Moulin, MD 10/19/15
(pdf)
View/Download
"EMS" in the New Healthcare Environment
MedStar Mobile Healthcare, Abbreviated Day-of Conference Presentation
Matt Zavadsky, MS-HSA, EMT 09/28/15
(pptx)
View/Download
"EMS" in the New Healthcare Environment
MedStar Mobile Healthcare, Comprehensive Presentation
Matt Zavadsky, MS-HSA, EMT 09/28/15
(pptx)
View/Download
CP Pilot Project
10/19/15
(docx)
View/Download
Failure to Rescue Top Ten Checklist - 2016 Update
Checklist
02/17/17
(pdf)
View/Download
2016 FTR Top Ten Checklist
HRETHEN 02/18/17
(pdf)
View/Download
2016 Undue Radiation Exposure Top Ten Checklist
Radiation
HRETHEN 02/18/17
(pdf)
View/Download

Current information regarding ARC activities and readmission reduction successes from our engaged hospital partners.
Title & Description Author Date Type
Beyond Hospital Walls: Strategies for Reducing Readmissions
Agenda from "Beyond Hospital Walls"
Christine Muscolo 04/24/13
(pdf)
View/Download
Getting Started and Moving Forward- Building Improvement Capacity
Pat Teske 01/19/11
(pdf)
View/Download
Breakout Session Key Discussion Points
"Beyond Hospital Walls" breakout summaries
Sam Spurlock 04/24/13
(pdf)
View/Download
ARC Update and Understanding the GAP
January 2011, GAP Analysis
Pat Teske 01/19/11
(pdf)
View/Download
California Association for Healthcare Quality
ARC Overview: CAHQ Journal
Pat Teske 01/05/14
(pdf)
View/Download
Improving Marketshare by Improving Value
Senior Leadership Dinner
Arnold Milstein MD and Kimberly Brayton MD, JD 04/22/14
(pptx)
View/Download
CA Hospital Penalties - Year 4
List of CA hospitals and their Medicare penalties in Year 4
ARC/Cynosure Health 08/05/15
(xlsx)
View/Download
California Readmission Summit Report
CARS
ARC 12/01/13
(pdf)
View/Download

Materials on pharmacy strategies to reduce re-hospitalizations.
Title & Description Author Date Type
Pharmacist Assisted Transition to Home
Pharmacy Approaches at Sequoia Hospital and Pathways Home Health and Hospice
Denise Schoenberger, PharmD and Virginia Bleiweiss Okabayashi, RPh 01/30/13
(pdf)
View/Download
Pharmacy Meeting Networking List
Pharmacy Contacts
Lisa Ehle 01/30/13
(pdf)
View/Download
Reducing Preventable Readmissions-A guide for Pharmacists
ACMC Fact Sheet
ACMC 01/11/12
(doc)
View/Download
Discharge Counseling Pilot High Risk Patients
Pharmacy Approaches at Santa Clara Valley Medical Center
Jessica Song, PharmD 01/30/13
(pdf)
View/Download
What is Medication Therapy Management (MTM)?
Learn about this Medicare outpatient pharmacy benefit.
Pat Teske 09/13/13
(pdf)
View/Download
Hosp Pharmacy 5-2013
Pharmacy
Aroop Pal, MDp; Stewart Babbott, MDp; and Samaneh Tavalali Wilkinson, MS, PharmD† 09/23/13
(pdf)
View/Download
Hosp Pharmacy - Readmissions in Psych 2013
Pharmacy
John R. Tomko, PharmD, BCPPp; Nadeem Ahmed, MD†; Koushik Mukherjee, MD‡; Rebecca S. Roma, MD, MBA‡; Donna DiLucente, BSNx; and Karen Orchowski, BSPharm{ 09/23/13
(pdf)
View/Download
Collaborating with Community Pharmacies to Reduce Readmissions
Safeway Pharmacy
Brian Hille, BPharm 10/10/13
(pdf)
View/Download
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)
View/Download
Collaborating with Community Pharmacies to Reduce Readmissions
Ralphs Pharmacy
Lord Sarino, PharmD 10/10/13
(pdf)
View/Download
Collaborating with Community Pharmacies to Reduce Readmissions
Walgreens
Duane Hanson & Ed Cohen, PharmD, FAPhA 10/10/13
(pdf)
View/Download
New Approaches to Community Pharmacist Interaction
Kevin Rodondi, PharmD & Marilyn Stebbins, PharmD 10/10/13
(pdf)
View/Download
ARC Webinar - Pharmacy Efforts to Reduce Readmissions
Pharmacy
Jeanette Cavano, Lynn Deguzman, Jaime Cavanaugh 04/02/14
(pdf)
View/Download

Here are resources focusing on specific conditions.

Using Health Information Technology to improve care transitions.
Title & Description Author Date Type
Early Learnings from CCTP
Terry Winter 12/04/12
(pdf)
View/Download
Technologies for Improving Post Acute Care Transistions
Center for Technology and Aging 11/30/10
(pdf)
View/Download
Technologies for Improving Post Acute Transistions- II
Lynn Redington, DrPH, MBA and Andrew Broderick 01/19/11
(pdf)
View/Download
Technologies for Improving Post-Acute Care Transitions
Lynn Redinton, DrPH, MBA and Andrew Broderick 01/19/11
(pdf)
View/Download
Using Health IT to Improve Management of Test Results that Return after Hospital Discharge
ARC Webinar
Martin Were 12/07/11
(pdf)
View/Download
Using IT in Care Transitions
ARC Webinar
Martin Were 03/21/12
(pdf)
View/Download
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)
View/Download
Team Communication to Reduce Hospital Readmissions: Marin General Hospital and CareInSync-COAST@Marin
Mobile Care Collaboration Platform
ARC and CHCF 03/19/14
(pdf)
View/Download
Good to Go: Using Technology to Improve Care Transitions
Cheryl Bailey, RN, BSN, MBA 10/10/13
(pdf)
View/Download

Resources related to other topics not listed above.
Title & Description Author Date Type
Avoid Readmissions- Potential Measures
ARC Webinar
Denise Remus 10/27/10
(pdf)
View/Download
CHART and IHA Analysis
Bruce Spurlock and Diane Stewart 01/19/11
(pdf)
View/Download
Models and Resources
Pat Teske 11/19/10
(doc)
View/Download
National Initiative- Local Implementation
Jennifer Wieckowski 02/23/12
(pdf)
View/Download
Partnerships with Patients and Families
Jim Conway 06/08/11
(pdf)
View/Download
FAQ: New CPT Transitional Care Management (TCM) Codes 99495-6
TCM Codes
06/11/13
(pdf)
View/Download
FAQ's-Billing Medicare for Transitional Care Management Services
Billing Medicare for Transitional Care Management Services
06/11/13
(pdf)
View/Download
CA Readmission Summit: Sponsorship Registration
Lisa Ehle 06/09/15
(pdf)
View/Download
Supporting Sponsors and Exhibitors
Names of Conference supporting Sponsors and Exhibitors
09/25/15
(pdf)
View/Download
ARC Closing Slides
Pat Teske 02/23/15
(pdf)
View/Download