Promising Practices for

Reducing Hospital Readmissions

Five Hospitals' Approaches

Five Hospitals' Approaches

Series//Reducing Readmissions

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Five Hospitals' Approaches

Learn how five programs aim to reduce potentially avoidable hospitalizations through better care transitions.


Five Hospitals' Approaches

Learn how 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.

Learn more

More from Aligning Forces for Quality (AF4Q)

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Latest: Care Coordination and Readmissions

Streamlining Data Decreases Preventable Readmissions

April 8, 2013

Newton-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, 2013

Methodist 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, 2013

Medina 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, 2013

Oregon 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, 2013

Since 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, 2013

Responding 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, 2013

Queen 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, 2013

Northern 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, 2013

Mercy 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, 2013

Seeking to reduce 30 day readmissions rates, Cullman Regional Medical Center sought to improve communication and patient understanding at the point of discharge.

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