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Tools & Resources

Here you will find provider resources from ARC's learning sessions including Webinar presentations and materials from in-person meetings. You will have the opportunity to download slides and other tools for your reference and use.

Do you have any resources that could be helpful for the community? Let us know.

Share Your Tools & Resources

Complete the following form if you have a tool or resource to share with the ARC communitiy.

Transition of Care Structures Assessment and Implementation Tools Research & Guides Community Pharmacy Patient Activation Information Technology Other


Assessment & Implementation Tools
Multi-disciplinary tools to support care transition efforts.
Title & Description Author Date Type
ARC Webinar - Intermountain Risk Score-Heart Failure and Myocardial Infarction Tool (IMRS-HF and IMRS-MI)
Predicting risk of readmission with IMRS-HF and IMRS-MI tools. 		Benjamin D. Horne, PhD, MPH, FACC, FAHA 07/10/13
(pdf)		 View/Download
Best Practice Intervention Practice
Acute Care Hospitalization 		Home Health Quality Improvement 03/05/14
(pdf)		 View/Download
End of Life Care
Title & Description Author Date Type
ARC Webinar - The Conversation Project: National Perspective and Local Implementation
Helping people talk about their wishes for end-of-life care. 		Marilyn Ababio & Mandy Ferguson 03/05/14
(pdf)		 View/Download
POLST Procedure Update-2015
Vincent Nguyen 04/06/15
(pdf)		 View/Download
Palliative Care
Title & Description Author Date Type
ARC Webinar - Implementation of Physician Orders for Life Sustaining Treatment (POLST)
Approach to end-of-life planning that emphasizes patient wishes. 		Dr. Jeff Yee & Dr. Vincent Nguyen 04/03/13
(pdf)		 View/Download
ARC Webinar - Palliatative Care in the Emergency Department
Emergency Physician model for providing Palliative Care. 		Travis E. DeVader, MD 05/01/13
(pdf)		 View/Download
Comparisons between palliative care consultation services in California hospitals from 2007 to 2011
Palliative Care Survey UCSF 		Dr. David O'Riordan 02/13/13
(pdf)		 View/Download
Palliative Care in Readmission Reduction
Steve Pantilat MD 10/14/11
(pdf)		 View/Download
Palliative Care Webinar
Palliative Care 		Partnership for PAtients 06/11/13
(pdf)		 View/Download
Sharp HospiceCare’s: A New Model for Late Stage Disease Management
Sharp HospiceCare 		Dr. Daniel Hoefer and Suzi Johnson 02/13/13
(pdf)		 View/Download
Patient Education
Title & Description Author Date Type
Resource from Chinese Hospital-please give credit if you use
Chinese Hospital 04/13/11
(pdf)		 View/Download

()		 View/Download
Reducing Hospital Readmissions With Enhanced Patient Education
Patient Education 		06/11/13
(pdf)		 View/Download
Improving Patient Education
Janet Grace, RN, BSN Saline Memorial Hospital 06/11/13
(ppt)		 View/Download
Discharge Processes
Title & Description Author Date Type
Nurse Navigator -ACMC
Nancy Halloran and Inger Harris 08/09/11
(pdf)		 View/Download
Comprehensive Discharge Planning and Home Follow-up of Hospitalized Elders
Mary Naylor et.al. 04/21/11
(pdf)		 View/Download
Comprehensive Discharge Planning for the Hospitalized Elderly
Mary Naylor 04/21/94
(pdf)		 View/Download
Discharge Follow-up Phone Call
Discharge Follow-up Phone Call 		06/11/13
(docx)		 View/Download
Discharge TIme Out
Discharge 		06/11/13
(docx)		 View/Download
Purple Discharge Folder
Discharge 		06/11/13
(doc)		 View/Download
Purple Discharge Folder Label
Discharge Folder 		06/11/13
(doc)		 View/Download
Protocol for Post Hospitalization Intervention Phone Call
San Francisco General Hospital 08/18/13
(pdf)		 View/Download
Discharge SFGH Transitional Care Program with Risk
San Francisco General Hospital 08/18/13
(pdf)		 View/Download
ARC Webinar - Leveraging Mobile Care Coordination Technology To Reduce Readmissions
CareInSync's collaboration with Marin General Hospital to build the nation's first 'Mobile Care Transitions Network'. 		Susan Cumming, MD & Siva Subramanian, PhD 09/04/13
(pdf)		 View/Download
Nursing Home Capabilities List
Skilled Nursing Facility 		Interact 3.0 04/07/14
(pdf)		 View/Download
ARC Webinar - Grand-Aides USA
Learn about the Grand-Aides program, an innovative post discharge workforce model that delivers personalized care at lower cost and prevents unnecessary hospital readmissions. 		Arthur Garson, Jr., MD, MPH 05/14/14
(pdf)		 View/Download
Teach back
Title & Description Author Date Type
Documenting and Doing
Dionette Kelton 02/23/12
(pdf)		 View/Download
In the Act- Teach Back
David Renfro 02/23/12
(pdf)		 View/Download
Support from Hospital to Home for Elders
Jeff Critchfield, Richard Santana and Diane Robbins 06/08/11
(pdf)		 View/Download
Teaching Teach Back
Staci Valdix 01/19/11
(pdf)		 View/Download
Health Literacy and use of Teach-Back for patient education
Teach back 		06/11/13
(pdf)		 View/Download
10 Elements of Competence for Using Teach-back Effectively
Teach Back 		06/11/13
(pdf)		 View/Download
Staff Competency Validation for Teach Back
Teach Back 		Missouri Hospital Engagement Network 06/11/13
(pptx)		 View/Download
Teach-back: A Health Literacy Tool to Ensure Patient Understanding
Teach Back 		The Iowa Health System Health Literacy Collaborative 06/11/13
(ppt)		 View/Download
Resident Tool Kit: Teach Back
Teach Back 		06/21/13
(pdf)		 View/Download
Teach Back Questions - CHF
Assessment and Implementation Tools 		Baptist Health Madisonville 09/23/13
(doc)		 View/Download
Teach Back Questions - Stroke
Assessment and Implementation Tools 		Baptist Health Madisonville 09/23/13
(doc)		 View/Download
Staff Education
Title & Description Author Date Type
Community Approach to Reducing Readmissions
Anya Vines 10/14/11
(pdf)		 View/Download
Reducing Preventable Readmissions-A guide for Nurses
ACMC Fact Sheet 		ACMC 01/11/12
(doc)		 View/Download
Reducing Preventable Readmissions-A guide for Pharmacists
ACMC Fact Sheet 		ACMC 01/11/12
(doc)		 View/Download
Reducing Preventable Readmissions-A guide for Physicians
ACMC Fact Sheet 		ACMC 01/11/12
(doc)		 View/Download
Reducing Preventable Readmissions-A guide for Social Workers
ACMC Fact Sheet 		ACMC 01/11/12
(doc)		 View/Download
Sample Report
Sample Report 		Pat Teske 09/13/11
(xls)		 View/Download
Referring Patients and Family Caregivers to Community-Based Services: A Provider’s Guide
Patient and Family Engagement 		Next Step In Care 07/19/13
(pdf)		 View/Download
Patient Activation and Health Literacy
Title & Description Author Date Type
Health Literacy
Jennifer Pearce 10/14/11
(pdf)		 View/Download
Motivational Interviews
Mindy Boccio 06/08/11
(pdf)		 View/Download
Partnerships with Patients and Families
Jim Conway 06/08/11
(pdf)		 View/Download
Patient Activation Measure
ARC Webinar 		Chris Delaney 12/15/10
(pdf)		 View/Download
Patient and Family Centered Care
Jenny Buchanan 06/08/11
(pdf)		 View/Download
Perfecting Patient Care Experience in Care Transitions
Teresa Childers 02/23/12
(pdf)		 View/Download
Patient Engagement Through Health Literate Care
Presentation from "Beyond Hospital Walls: Strategies for Reducing Readmissions" 		Jennifer Pearce 04/24/13
(pdf)		 View/Download
Top Ten Things You Need to Know About Engaging Patients
Institute For Health Technology 04/01/11
(pdf)		 View/Download
Health Literacy Universal Precautions Kit
Health Literacy 		AHRQ 06/11/13
(pdf)		 View/Download
Health Literacy Universal Precautions Kit
Health Literacy 		AHRQ 06/11/13
(pdf)		 View/Download
RI Hospital ICU Patient Brochure
Patient Activation 		RI Hospital 06/11/13
(pdf)		 View/Download
ARC Webinar - Patient and Family Engagement: Recruiting for Patient Family Advisory Councils & A Review of Engagement Tools
Libby Hoy & Julia Hallisy, DDS 01/08/14
(pptx)		 View/Download
Always Events® Getting Started Kit
Patient and Family Engagement 		IHI 03/21/14
(pdf)		 View/Download

()		 View/Download
Empowered Patient Hospital Guide for Patients and Families
Julia Hallisy 06/14/15
(pdf)		 View/Download
Implementation-Risk Assessment
Title & Description Author Date Type
LACE Tool
Ron Krielkamp 08/09/11
(pdf)		 View/Download
Readmission Formula
Formula 		Pat Kearns, MD 10/12/11
(doc)		 View/Download
RI Hospital Communication Bundle
Individual Quality Measurement Gap Analysis Data Collection Tool Kit 		RI Hospital 06/11/13
(doc)		 View/Download
The Communication Bundle Quality Measures
Modules 		06/11/13
(pdf)		 View/Download
RI Hospital Communication Bundle 2
Quality Measures 		06/11/13
(doc)		 View/Download
Risk Assessment Formula
Formula 		Pat Kearns, MD 10/12/11
(doc)		 View/Download
Peninsula Circle of Care Readmit Interview Form
Risk Assessment 		Peninsula Circle of Care 04/07/14
(pdf)		 View/Download
Peninsula Circle of Care Risk for Readmission Tool
Risk Assessment 		Peninsula Circle of Care 04/07/14
(pdf)		 View/Download
Standard Work for ED Notification for Potential Project Re-Engineering Discharge (RED) Patients
Eric Gillens 03/16/15
(pdf)		 View/Download

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