{"text_format":"1","workbook":"xlsx","n_sheets":1,"sheets":["Readmissions"],"not_rendered":{"charts":0,"images":2,"macros":1,"external_links":0,"defined_names":127,"comments":0,"pivot_tables":0},"unopened":[],"bounds":{"document_bytes":16777216,"sheet_cells":100000,"rows_first":2000,"rows_last":500,"rows_between":2000,"halvings":0,"cell_chars":16384,"cell_head_chars":4096},"cells_cut":0,"cells_raw":0,"read":"whole","date_system":"1900"}

{"sheet":"Readmissions","index":0,"n_rows":46,"n_cols":35,"rows_kept":46,"cut":false,"hidden":false,"merged":[[45,2,45,17],[0,1,3,1],[4,0,4,20],[13,0,19,0],[5,32,5,33],[6,32,6,33],[20,32,20,33],[27,32,27,33]]}
[]
[]
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["In the section below, please enter an \"y\" or \"n\" for each patient being tracked to indicate if the following elements were completed. Note: All fields must be filled in. "]
["Dates being tracked:","Please enter the current period being tracked here:"]
["Element","Best Practice","Patient Sample"]
[null,null,1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,"Total","Percentage"]
["Patient ID# (optional)",null,"ID# HERE","ID# HERE","ID# HERE","ID# HERE","ID# HERE","ID# HERE","ID# HERE","ID# HERE","ID# HERE","ID# HERE","ID# HERE","ID# HERE","ID# HERE","ID# HERE","ID# HERE","ID# HERE","ID# HERE","ID# HERE","ID# HERE","ID# HERE","ID# HERE","ID# HERE","ID# HERE","ID# HERE","ID# HERE","ID# HERE","ID# HERE","ID# HERE","ID# HERE","ID# HERE"]
["Patient identified as a readmission","Patient readmitted within 30 days            ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"COUNTIF(C10:AF10,\"y\")","v":0},{"$f":"IFERROR(AG10/(AG10+AI10),\"0\")","v":"0"},{"$f":"COUNTIF(C10:AF10,\"n\")","v":0}]
[null,"Readmitted from SNF ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"COUNTIF(C11:AF11,\"y\")","v":0},{"$f":"IFERROR(AG11/(AG11+AI11),\"0\")","v":"0"},{"$f":"COUNTIF(C11:AF11,\"n\")","v":0}]
[null,"Multi-visit patient: Four or more inpatient admission in 12 months (or hospital criteria)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"0",0]
[null,"If the answer is yes to any of the above three questions, patient and care partner interview to be completed",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"0",0]
["Care partner","Care partner identified in EMR  ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"0",0]
[null,"Preferred contact method for care partner documented",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"0",0]
[null,"Care partner documented and visible to healthcare team, i.e. white board, rounding form, EMR, huddle board",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"0",0]
[null,"Care partner participates in rounding ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"0",0]
[null,"Patient status update provided and discussed daily with care partner",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"0",0]
[null,"Care partner given My Care Transition brochure or way to document questions/concerns",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"0",0]
[null,"Readmission Risk Assessment (admission assessment component) completed for patient with care partner",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"0",0]
["Patient and care partner education","Patient and care partner educated on:   ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0]
[null,"Diagnosis(es)      ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"0",0]
[null," Worsening signs and symptoms (red flags)   ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"0",0]
[null,"Promptly reporting worsening symptoms ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"0",0]
[null,"Self care management (monitoring symptoms, adherence to treatment plan, diet, exercise, smoking)  ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"0",0]
[null,"High-risk medications",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"0",0]
[null,"Consult with pharmacist for patient education prior to discharge for patients on high-risk medications ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"0",0]
[null,"Patient and care partner educated on:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0]
[null,"The importance of taking prescribed medication    ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"0",0]
[null,"How to take anticoagulants, insulin, opioids medications (dosage and frequency)  ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"0",0]
[null,"Medication side effects  ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"0",0]
[null,"Safety risks",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"0",0]
[null,"Teach back with patient and care partner ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"0",0]
["Discharge planning","Discharge plan reviewed with patient and care partner ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"0",0]
[null,"Follow-up appointment made within 7 days after discharge",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"0",0]
["Care transitions","Verbal handoff to next provider of care",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"0",0]
[null,"Written discharge summary forwarded to next provider of care within 24 hours",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"0",0]
[null,"Post-discharge follow-up phone call (48 - 72 hours after)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"0",0]
["Post-hospital care services (as appropriate)","Home care services arranged",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"0",0]
[null,"Durable medical equipment ordered ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"0",0]
[null,"Referral to food banks or meals on wheels",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"0",0]
[null,"Referral to social services or other agency to address social determinants of health (housing, transportation, heat, financial or insurance assistance)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"0",0]
[null,"Referral to disease management programs (COPD, CHF, diabetic educator)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"0",0]
[null,"Other personal care or services",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"0",0]
[null,"Other _____________________   ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"0",0]
[null,"\n","This material was prepared by the Healthcare Association of New York State, Inc., a Hospital Quality Improvement Contractor under contract with the Centers for Medicare & Medicaid Services, an agency of the U.S. Department of Health and Human Services. Views expressed in this material do not necessarily reflect the official views or policy of CMS or HHS, and any reference to a specific product or entity herein does not constitute endorsement of that product or entity by CMS or HHS. 12SOW/EQIC/HQIC-0013-12/09/22",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0]