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.

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* 1. Name of Nursing Home

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* 2. State

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* 3. Month of Reporting (Please select the month for which your are reporting the data.)

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* 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

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* 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.