Community & Post‑Acute Partnerships Toolkit

Practical templates, agreements, and workflows to create reliable handoffs between hospitals, post‑acute providers, primary care, and community services.

What you'll understand and accomplish

Use the toolkit to map typical transition pathways, clarify who is responsible at each step, standardize medication reconciliation, create shared‑care plans, and set timelines for follow‑up. Teams will learn how to reduce information gaps that lead to confusion, delayed care, and avoidable readmissions.

Who benefits

Designed for discharge planners, care coordinators, nurses, case managers, physicians, quality leaders, and administrators working across hospitals, home health agencies, skilled nursing facilities (SNFs), primary care practices, and community‑based organizations.

How to use the toolkit in practice

Start with the templates during multidisciplinary huddles to surface handoff problems and negotiate local agreements. Tailor role definitions and timelines to receiving‑provider capacity and regulatory requirements. Convert checklists into interactive forms to capture structured handoff data and save transitions for audit or follow‑up.

Examples from everyday care

- A hospital discharge team uses a shared‑care plan template to ensure home health has the correct med list, equipment orders, and a first‑visit window within 24–48 hours.
- A primary care practice receives standardized transition summaries that let clinicians prioritize high‑risk patients for early follow‑up visits.
- A hospital and local SNF agree on a streamlined acceptance checklist that reduces back‑and‑forth phone calls and prevents delays in placement.

Where this fits in the wider care‑coordination ecosystem

This toolkit complements the Care Coordination & Transitions domain by focusing on shared agreements and operational handoffs—practical building blocks that help organizations deliver safer, more reliable transitions and measure improvement over time.

Platform opportunities: consider tailoring the toolkit as an ownable collection for your site, or using interactive form rendering to capture and store handoff data for audits and continuous improvement.