Promising Practices for
Reducing Hospital Readmissions
Reducing Readmissions
Five Hospitals' Approaches
These five programs aim to reduce potentially avoidable hospitalizations through better care transitions.
About Readmissions
Our fragmented health care system fails to coordinate patients' care among different doctors' offices and hospitals. Without that coordination, patients discharged from hospitals don't get support and encouragement to take their pills, follow their diets, show up for follow-up appointments, or otherwise follow the regimens that doctors have prescribed during their hospitals stays. Poor care coordination contributes to the revolving door syndrome at America's hospitals in the name of readmissions.
Quick Facts:
- Preventable readmissions cost Medicare about $12 billion a year.
- Rehospitalization is a frequent, costly, and sometimes life-threatening event that is associated with gaps in follow-up care.
- Three-fourths of chronically ill patients who leave the hospital wouldn't need a return trip if they had a plan for follow-up care.
Related Content
Care About Your Care:
Improving Transitions. Reducing Readmissions.
A national conversation highlighting efforts to improve care transitions, reduce avoidable hospital readmissions, and lift the overall quality of care.
More from Aligning Forces for Quality (AF4Q)
Latest: Care Coordination and Readmissions
Streamlining Data Decreases Preventable Readmissions
April 8, 2013Newton-Wellesley Hospital implemented a variety of initiatives focused on improving its discharge process. Two critical components of the project included streamlining its data collection and enhancing communication between hospital staff.
Hospital Focuses on Community Engagement to Help Reduce Readmissions
April 8, 2013Methodist South Hospital formed a multidisciplinary in-hospital team to develop interventions targeted at reducing the hospital’s readmissions rate.
Readmissions Database Helps Hospital Curb Readmissions
February 27, 2013Medina hospital created a readmissions database and set up a new workflow process to target heart failure patients with education to avoid a readmission to the hospital. Over 18 months, readmissions were reduced by 9 percent.
Heart Failure Education Reduces Readmissions
February 26, 2013Oregon Health and Science University cut readmissions for heart failure patients by 11 percent over an 18-month period through improved patient education.
Nurse Care Advocate Improves Heart Failure Care
February 26, 2013Since implementing a Care Advocate position, Marymount Hospital has steadily maintained 100 percent compliance with core measures for heart failure care and reduced its heart failure readmission rate by 26 percent.
Transitions Navigator and Hospital Readmissions
February 15, 2013Responding to newly emerging models of coordinated care, staff at University of Utah Health Care piloted hiring a transitions navigator, leveraging best practices from national care transitions leaders.
Community-Wide Safety Net Improves Care Transitions
February 15, 2013Queen of the Valley Medical Center uses the CARE Network to ensure a seamless continuum of care from hospital discharge back into the community setting is established.
Care Manager Program Reduces Risk of Readmission
February 15, 2013Northern Piedmont Community Care implemented a nurse care manager program, which utilizes home visits with patients recently discharged from the hospital to make sure that a care plan is established and followed.
Care Transitions Nurses Reduce Risk of Avoidable Hospital Readmissions
February 15, 2013Mercy Health in Cincinnati, Ohio implemented Dr. Eric Coleman’s care transitions model by using nurses specially trained to act as patients’ guides through the discharge process.
Recording Instructions Improves Discharge and Satisfaction
February 15, 2013Seeking to reduce 30 day readmissions rates, Cullman Regional Medical Center sought to improve communication and patient understanding at the point of discharge.