Skilled Nursing Facility Care Coordination Toolkit

Collaborating with partners, providers, patients, families, and caregivers to improve and lower healthcare costs.

Skilled Nursing Facility Care Coordination Toolkit

An overview of care coordination best practices to avert hospital readmissions

Download available at: care-coord-tools

Table of Contents

Executive Summary Readmission Prevention .................................................................................. 1.0

Skilled Nursing Facility (SNF) Resident Rehospitalization Tip Sheet Top 10 Things to Know About SNF Readmissions Measure SNF Readmission Exclusion Criteria Accessing Official Rehospitalization Data Tip Sheet Readmission Pre/Post Assessment Readmission PIP Sample Readmission Strategy Tree Sample

Reducing Adverse Drug Events.........................................................................2.0

Warfarin: Why you Need it, How it's Monitored, Interactions to Recognize Reducing Diabetic Agents Adverse Drug Events Diabetes Education: Use Teach-Back to Help Patients Successfully Manage Their Insulin Opioids: Centers for Disease Control and Prevention (CDC)Prescribing Guidelines for Clinicians

Readmission Tools .......................................................................................... 3.0

SNF Shared Best Practices to Reduce Potential Preventable Readmissions SNF Transfer Checklist SNF Pre-Admission Huddle Equipment Checklist SNF Re-Hospitalization Risk Assessment

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Patient Education Tools and Resources............................................................4.0

Zone Tools Heart Failure Sepsis COPD

Welcome to SNF Brochure Guidelines Welcome to SNF Brochure Template

Teach-Back ...................................................................................................... 5.0

Teach-Back Can Help Practice Using Plain Language Teach-Back Sentence Starters Teach-Back Validation Tool

This material was prepared by Health Services Advisory Group, the Medicare Quality Innovation Network-Quality Improvement Organization for Arizona, California, Florida, Ohio, and the U.S. Virgin Islands, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. QN-11SOW-XC-07092019-01

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Executive Summary

Reducing readmissions in skilled nursing facilities (SNFs) is a top priority for the Centers for Medicare & Medicaid Services (CMS). Research shows that more than 20 percent of Medicare beneficiaries discharged from a hospital to a SNF will return to a hospital within 30 days, costing Medicare more than $4 billion per year.1 These returns are often due to potentially preventable conditions, such as dehydration, infections, medication errors, and unaddressed social needs.

As your CMS Quality Improvement Organization (QIO), Health Services Advisory Group (HSAG) is committed to improving the quality of care delivered in each state it serves. This includes the self-directed Reducing Readmissions Preparation Program (RRPP), which is designed to help improve knowledge on the new readmission quality measures, identify strategies to prevent readmissions, and help facilities be a preferred provider to their local hospitals.

Nationally, readmissions cost

Medicare $26 billion dollars annually, of which

HSAG knows organizations like yours are committed to ensuring that residents have the necessary tools and care in place prior to discharge. Your efforts provide residents the opportunity to heal in the home setting with loved ones. Employing these tools can help improve organizational quality metrics and maximize financial incentives. HSAG hopes the information in this toolkit will assist you and your organization improve care coordination and reduce readmissions.

$17 billion are potentially avoidable.2

For assistance or further information, please reach out to your state's HSAG office.

State Arizona California Florida Ohio

Telephone 602.801.6916 818.265.4672 813.865.3459 614.360.2748

Email aznursinghome@ canursinghomes@ FL-NNHQCC@ ohnursinghome@

Find more about care coordination at: care-coordination

Sources: 1. Mor V, Intrator O, Fen, Z, Grabowski DC. The revolving door of rehospitalization from skilled nursing facilities. Health Affairs. 2010: 29(1). Available

at: 2. Rau J. Medicare Fines 2,610 Hospitals In Third Round of Readmission Penalties. Kaiser Health News. 2014. Available at:

. Accessed March 11, 2019.

1.0 Readmission Prevention

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