Reform in Action: How the U.S. Health Care System Can Reduce Avoidable Readmissions

Insights from the Robert Wood Johnson Foundation and Aligning Forces for Quality

Patients discharged from U.S. hospitals return far too often. Almost one in five elderly patients released from a hospital is back within 30 days, and more than one in three are back within 90 days. Although some readmissions are part of a patient’s treatment plan, many are avoidable. They are the result of a fragmented system of care that too often leaves discharged patients confused about how to care for themselves at home, unable to follow instructions they didn’t understand, not taking medications properly or getting the necessary follow-up care, and ultimately leading them to return to the hospital. These unnecessary readmissions negatively affect patients’ health, place a burden on their families and caregivers, and cost our country billions of dollars.

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10 Things You Should Know About Care Transitions

These ten facts from Care About Your Care show why care transitions are so critical, outline key areas of concern, and share how the health care system is focusing on improvement.

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Reducing Avoidable Readmissions through Better Care Transitions

Traditionally, efforts to reduce avoidable readmissions have focused on hospitals, but it is becoming clear that many factors along the care continuum influence readmissions. These innovative national models take a broader view of care transitions, and are implementing a variety of interventions aimed at reducing avoidable readmissions.

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How to Avoid Being Readmitted to the Hospital

Traditionally, efforts to reduce avoidable readmissions have focused on hospitals, but it is becoming clear that many factors along the care continuum influence readmissions. These innovative national models take a broader view of care transitions, and are implementing a variety of interventions aimed at reducing avoidable readmissions.

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Hospital Discharge Checklist and Care Transition Plan

Asking questions, asking for a plan, and making sure you know what do to if your symptoms get worse can help you stay out of the hospital. If your hospital does not provide similar tools, use the Care About Your Care discharge checklist and care transition plan.

Download the discharge checklist and transition plan in English or Spanish