STAT Homepage | Root Cause Analysis | Coalition Building | Interventions | Educational Tools
Provider Education Tools for Care Transitions
| Direct Technical Assistance | Care Transitions Toolkit | Readmission Reports | Quick Start Guide to Care Coordination |
Home Health, Hospice & Palliative Care
- DOWNLOAD ALL RESOURCES
in Home Health, Hospice & Palliative Care (.zip file) 
The Gift Initiative
Rehospitalization Clinical Review Tool
Rehospitalization Audit – Home Health
Chart Review for Unplanned Transfers
Post ACH/ROC Audit and Tally Tool
Process of Care Tool Home Health
Home Health Agency Change Package
Process of Care Investigation Tool – Home Health
Hospital Readmissions Trifold – Home Health
Hospital Readmissions Trifold – Hospice
Improving Care Coordination and Transitions through Learning & Action Networks – Home Health
Care Transitions Tools and Resources
How-to Guide: Improving Transitions from the Hospital to Home Health Care to Reduce Avoidable Rehospitalizations
Why Not The Best? A Healthcare Quality Improvement Resource
Hospital to Home (H2H) National Quality Initiative
Home Health Interview Form
10 Reasons Physicians Should Consider a Hospice Consultation
Hospice Change Package
10 Facts Physicians Need to Know About Physician Orders for Life-Sustaining Treatment (POLST)
Speak Up Initiative
Ask Me 3
Health Literacy Manual
Comprehensive End of Life Resources
Advance Care Planning: Preferences for Care at the End of Life- Health Information in Multiple Languages
The Darthmouth Atlas of Healthcare
National Transitions of Care Coalition (NTOCC)
Center to Advance Palliative Care: Palliative Care Tools, Training & Training Assistance
The Home Health Quality Improvement (HHQI) National Campaign is dedicated to improving the quality of care provided to America’s home health patients.
STAT Home Health Interventions
Hospital Care
RARE Campaign
Chart Review
Observation Tool for Patient Teaching
Organizational Assessment Guide
Population Health Worksheet
SWOT
Typical Failures
Hospital Chart Review
Hospital Interview SheetSTAAR How-to Guides
STAAR How-to Guides
Improving Transitions from the Hospital to Skilled Nursing Facilities to Reduce Avoidable Rehospitalizations
Improving Transitions from the Hospital to Home Health Care to Reduce Avoidable Rehospitalizations
Improving Transitions from the Hospital to Post-Acute Care Settings to Reduce Avoidable Rehospitalizations
- DOWNLOAD ALL RESOURCES
in Hospital Care (.zip file) 
Chart Review for Hospitals
Readmissions Root Cause Analysis Tool
Chart Audit Tool for Hospitals
Readmissions Work Sheet
Improving Care Coordination and Transitions through Learning & Action Networks – Hospitals
Hospital Care – Care Transitions Tools and Resources
STAT Rehabilitation Services & Discharge Screening Tool 
STAT Discharge Criteria Tool
Community Progress Tool – Excel | Word
Care Transitions Intervention
Project RED: Re-Engineering Discharge
The Re-Engineered (RED) Toolkit – Spanish language template for the After Hospital Care Plan
Project BOOST: Better Outcomes for Older Adults through Safe Transitions
The Partnership for Patients
Heart Talk Series 1 – Evidence-based Education for Health Care Professionals
The Bridge Program
Nursing Home Care
- DOWNLOAD ALL RESOURCES
in Nursing Home Care (.zip file) 
Readmission Root Cause Analysis Tool – Skilled Nursing Facility
Chart Review Skilled Nursing Facility
Hospital Readmissions Trifold – Nursing Homes
Improving Care Coordination and Transitions through Learning & Action Networks – Nursing Homes
How-to Guide: Improving Transitions from the Hospital to Skilled Nursing Facilities to Reduce Avoidable Rehospitalizations
SNF Change Package
Nursing Home Staff Interview
Help Decrease Avoidable Hospitalizations Poster (11×17)- Heart Talk Series 2 – Education for Nursing Assistants
STAT SNF Interventions
Physician Office Care
- DOWNLOAD ALL RESOURCES
in Physician Office Care (.zip file) 
Hospital Readmission Trifold – Physician Offices
Improving Care Coordination and Transitions through Learning & Action Networks – Physician Offices
Physician Office – Care Transitions Tools and Resources
How-to Guide: Improving Transitions from the Hospital to Post-Acute Care Settings to Reduce Avoidable Rehospitalizations
Our Practice Works to Prevent Unnecessary Readmissions Post It Note Template
Your Recently Discharged Patients Needs Post It Note Template
Physician Office Assessment Form
Physician Office Change Package
Physician Office Communications Needs Assessment- Heart Talk Series 1 – Evidence-based Education for Health Care Professionals
IHPC NCC – Engaging Physicians in Improving Care Transitions and Reducing Readmissions
Community Support Organizations
Improving Care Coordination and Transitions through Learning & Action Networks – Community Support Organizations
The Empowered Patient Coalition
All Provider Types
- Transitions of Care videos
- DOWNLOAD ALL RESOURCES
in All Provider Types (.zip file) 
Asthma Zone Tool
Depression Zone Tool
Foley Catheter Zone Tool
Respiratory Zone Tool
Physical Therapy Zone Tool
Heart Disease Zone Tool
Assessing Family Caregivers: A Guide for Healthcare Providers
Communicating with Your Medicare Patients
STAT In-Patient Facility Interventions
Health Literacy Toolkit
Transition Discharge Planning Toolkit
This page is funded by our Medicare QIO Program Contract.
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