Texoma Care Transition Coalition
May 7, 2020 @ 9:00 am - 10:30 am
Texoma Care Transition Coalition Mission
The mission of the Texoma Care Transition Coalition is to enable safe and effective transitions of patients between all settings of care, and empowering patients and their families to manage their health.
Coalition Areas of Expertise
- Physician Practices
- Palliative Care Organizations
- Palliative Care
- Health Care Providers
(Hospitals, ACO, LTAC, IRF)
Information & Discussion
Below you’ll find the root cause analysis for you to download & review, and assess your particular facility. This is a very important “1st step” of this process. Please bring your findings to the meeting and be prepared to discuss areas of concern and possible solutions to problem areas. Remember, we are here on a mission, to reduce re-hospitalizations long term and to communicate and improve the exchange of core clinical information among providers, caregivers, families, patients and other authorized entities. The more involved you are, the quicker we can work as a successful community team to accomplish this goal.
We know simply raising broad awareness of better practice will not achieve sustainable results. It will not change behaviors on a large scale unless communities share, interact, ask, integrate and implement to create a forceful momentum for change!
ACH Clinical Record Review Tool
ACH is a good home health tool for looking at processes.
Assessment For Services HHA
Home Health Agencies Assessment for Services form.
Assessment For Services SNF
Skilled Nursing Facilities Assessment for Services form.
Audit Tool SNF-2
Audit Tool SNF is for SNF’s chart audits. You look at 5-10 readmit patient charts and look for trends as to why they returned.
Warning Signals for Congestive Heart Failure.
CMS Discharge Checklist
Your Discharge Planning Checklist.
Suggested Coaching Script, easing the transition from hospital to home.
Coaching Talking Points
Coaching talking points.
COPD Zone Tool
Self management plan for Chronic Obstruction Pulmonary Disease (COPD).
Discharge Risk Assessment
Discharge Risk Assessment (to be completed 2 days prior to discharge).
Health Literacy Tip Sheet
Health literacy tip sheet.
In-Patient Survey Data Collection Tool
Patient discharge survey.
HH Interview Guide
The Interview Guide is for root cause and is directed for home health staffing questions to look at staff perception.
Interview Guide SNF
The Interview Guide is for SNF’s root cause and is directed for SNF’s staffing questions to look at staff perception.
JT Audit Tool
JT Audit tool is for home health chart audits. You look at 5-10 readmit patient charts and look for trends as to why they returned.
Match Toolkit AHRQ 2012
Medications at Transitions and Clinical Handoffs (MATCH) for medication reconciliation.
Methods Process of Care Hospice
Methods Process of Care Hospice is an algorithm for hospice audits to look at the hospice processes.
PA Chart Review Audit Tool HH
PA Chart Review Audit Tool is geared more for hospitals. Choose which one works best.
Survey In-Patient Data Collection Tool
Survey in patient is a good tool to assess if a patient carried through on their discharge plans and to see if there was a problem.
Get started implementing the Care Transitions Intervention in your community.