Reducing Hospital Readmissions

A collection of research and resources highlighting the causes of avoidable hospital readmissions, case studies, and strategies to improve care transitions.

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 A nurse checks a female hospital patient.

Our health care system suffers from a chronic malady—the revolving door syndrome at its hospitals. Some return hospital trips are predictable elements of a treatment plan. Others are unplanned but difficult to prevent: patients go home, new and unexpected problems arise, and they require an immediate trip back to the hospital. But many of these readmissions can and should be prevented.

What Are Hospital Readmissions?

According to a RWJF/Health Affairs analysis of the Medicare Hospital Readmissions Reduction Program, readmissions refers to a patient being admitted to a hospital within a certain time period from an initial admission - generally within 30 days of an initial hospital stay. If a hospital has a high proportion of patients readmitted within a short time frame, it may be an indication of inadequate quality of care in the hospital or a lack of appropriate coordination of postdischarge care.

Stemming from multiple initiatives connected with our work to improve health care in the U.S., this collection includes research and case studies on the causes and ramifications of avoidable hospital readmissions, and resources for health care practitioners and others who are working to reduce readmissions and improve care transitions.

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Improving Transitions in Care

June 13, 2014

Barnabas Health in northern New Jersey developed the Transitions in Care program to improve transitions for frail adults age 65 and older with dementia and at least one other condition from the hospital to their home or a long-term care facility.

Woodbury, N.J., High-Risk Seniors Avoid Hospital Readmissions Through a Care Transitions Program

May 15, 2014

Inspira Medical Center Woodbury in New Jersey created a Care Transitions Program for high-risk seniors discharged from the hospital to other facilities or their homes. It improved their outcomes and reduced hospital readmissions.

A Revolutionary Approach to Improving Health Care Delivery

February 1, 2014

Jeffrey Brenner, MD, created a model for improving care while reducing costs for complex patients who are "superutilizers" of the health care system. After using claims data to identify these patients, teams offer personalized care management.

Medicare Hospital Readmissions Reduction Program

November 12, 2013 | Brief

Although not all readmissions can be prevented, research shows that there are strategies that hospitals can employ to avert many readmissions.

Hospitals With Higher Nurse Staffing Had Lower Odds Of Readmissions Penalties Than Hospitals With Lower Staffing

October 7, 2013 | Journal Article

The aim of the program is to reduce readmissions while aligning hospitals’ financial incentives with payers’ and patients’ quality goals.

A nurse provides discharge instructions to a patient.

Watch the video to learn about innovative solutions from communities across America.

Watch the video to learn about innovative solutions from communities across America.