Home Health Quality Campaign – Rehospitalization Toolkit

This goal is to reduce the number of rehospitalizations for home care patients using tele-triage and other resources.

Tele-Triage Zone Tools– Increase tele-triage opportunities before emergency department with these zone tools, available for COPD, Depression, Diabetes, Heart Disease, Heart Failure, High Blood Pressure, Pain Management, and Wound Management. Also, conduct chart reviews or survey recent patients hospitalized without first contacting the agency (except 9-1-1 type of emergencies). Provide phone monitoring on Fridays (or on weekend) for high- risk patients.

Performance Improvement Process for Rehospitalizations

Call Me First Posters

Stop and Watch Early Warning Tool

Hospital Risk Assessment

Stop Light Tools:


Heart Failure

My Emergency Care Plan

Patient Workbooks

LACE Risk Assessment

Flowchart for High-Risk Patients

Nurse to Nurse Handoff Report

30-Day Readmission Tool

Phone Monitoring Assessment Guides:

Heart Failure Guide

COPD Guide

Diabetes Guide

Cancer Guide

Medication Management Guide

Patient Encounter Form

Phone Monitoring Checklist

HHQI Zone Tools