Facility: / Auditor Name: / Signature:
Time Period Reviewed: / Date of Review:
Best Practices / #1 / #2 / #3 / #4 / #5 / #6 / #7 / #8 / #9 / #10 / Total Charts / Total Possible / % Yes
1. Assessment tools for risk levels for readmission
  • Risk assessment for re-hospitalization completed at SOC and ROC and when significant change in condition

  • Health literacy assessment completed upon admission

  • Medication management and reconciliation including review of appropriateness of medications for the elderly, duplication, efficacy, side effects and untoward effects at SOC and each skilled visit

  • Fall risk assessment done at SOC and ROC

2. Interventions for patient management
  • Front-loaded visits during the first 2-3 weeks

  • Tele-health monitoring utilizing structured calls and monitored collection of patient specific data

  • Fall prevention program implemented for patients identified as high risk for falls

  • Pharmacist utilized for poly-pharmacy patients – more than 5 medications, new medications for cardiac condition, other complex conditions

  • ZONE Tools utilized for patient teaching for HF, COPD, and DM

  • Emergency Care Plan utilized to teach patient how to identify symptoms of exacerbation and action to take

Best Practices / #1 / #2 / #3 / #4 / #5 / #6 / #7 / #8 / #9 / #10 / Total Charts / Total Possible / % Yes
  • Disease management teaching of the patient with a chronic disease within 1 week of admission and weekly thereafter

  • Teach-back method used with resident/family regarding plan of care implementation and follow through

  • Patient Personal Health Record available and updated by the patient/family with changes in medications and care plan

  • Post-hospital physician appointments completed with 1 week for high risk patients and 2-3 weeks for others

  • Appropriate referrals to SW, PT, and ST within 48 hours of SOC/ROC based on ADL and IADL scores and diagnoses

3. Communication tools/methods
  • S-BAR documentation completed prior to communicating with physician

  • Case conference discussion of all high risk patients weekly

  • Documentation of verbal communication with hospital nursing and/or case management staff on transfer to the hospital

  • Universal transfer tool with comprehensive patient information received from the hospital at patient admission to the home health agency

  • Universal transfer tool with comprehensive patient information sent to the hospital within 24 hours of agency knowledge of re-admission

Best Practices / #1 / #2 / #3 / #4 / #5 / #6 / #7 / #8 / #9 / #10 / Total Charts / Total Possible / % Yes
4. Quality Improvement
  • Case conference review of all unplanned visits to the ED or admissions to the hospital

  • Collection of monthly data on interventions implemented to measure success rates

  • Collection of monthly data on re-admission rates

  • Monthly review of results of monitoring utilizing PDSA to revise or change interventions

5. Other




NOTES:


This material was prepared by TMF Health Quality Institute, the Medicare Quality Improvement Organization for Texas, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy. 10SOW-TX-C8-11-24

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