SIP1_Palliative Care Data Collection Tool Please take a few minutes to provide the following information related to residents in the nursing home. It will be used to monitor the performance on the quality improvement goals of this effort to include reducing unnecessary hospital transfers and readmissions among residents receiving palliative care. Question Title * 1. Name of Nursing Home Question Title * 2. State Georgia North Carolina Question Title * 3. Month of Reporting (Please select the month for which your are reporting the data.) April 2017 May 2017 June 2017 July 2017 August 2017 September 2017 October 2017 November 2017 Dec 2017 January 2018 February 2018 March 2018 April 2018 May 2018 June 2018 July 2018 Question Title * 4. Please provide numerical value for following: Total number of documented advanced care plan forms for residents during the reporting month Total number of hospital admissions for residents during the reporting month Average Daily Census Total number of acute care transfers among residents during the reporting month Total number of ED visits for residents during the reporting month Total number of observation stays for residents during the reporting month Total number of 30 day hospital re-admissions for residents during the reporting month Question Title * 5. Please provide your contact information Name of the person completing this form Contact Details (phone number and email) Thank you for completing this form. Done