This resource is a modified version of the LACE tool, focused on nursing; and incorporating additional checklists for more comprehensive discharge planning and assessment.

The LACE tool is one of meany designed to assess risk of patient readmission or death upon discharge.

The 8P Screening Tool is designed to identify a patient's risk for adverse events after discharge.

The National Database of Nursing Quality Indicators® (NDNQI®) delivers evidence to support the importance of nurse sensitive measures in overall patient experience strategy.

The CALNOC registry captures and benchmarks unit data, structural measures, process measures, and outcome measures.

This publication includes the definition of CCTM, defining characteristics for RNs practicing in the CCTM role, and an initial conceptual framework that was adapted from models cited in the Care Coordination and Transition Management Core Curriculum. The framework offers a structure for cataloguing and unifying the distinct relationships and interactions among the professional nurse, the patient, group and/or population, the inter-professional health care team, and the resources across the health care continuum.

Dementia Care MappingTM is designed to empower staff teams to engage in evidence-based critical reflection in order to improve the quality of care for people living with dementia. It provides a direct and ongoing evidence base for practice and practice change. As such, it provides an excellent example of the principles of care mapping, in general; for any condition.

A functional assessment tool used for care planning with the geriatric patient.

The Chronic Care Model summarizes the basic elements for improving care in health systems at the community, organization, practice and patient levels.

This document reflects the work of the Institute for Healthcare Improvement (IHI) to develop a state-wide strategy for reducing avoidable rehospitalizations.