Health Care Leader Action Guide to Reduce Avoidable Readmissions

Commonwealth Fund

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Reducing avoidable hospital readmissions is an opportunity to improve quality and reduce costs in the health care system. This guide, developed by the Health Research and Educational Trust, is designed to serve as a starting point for hospital leaders to assess, prioritize, implement, and monitor strategies to reduce avoidable readmissions. The guide is available as a PDF and requires Adobe Reader.

Health Care Leader Action Guide to Reduce Avoidable Readmissions

Reducing avoidable hospital readmissions is an opportunity to improve quality and reduce costs in the health care system. This guide, developed by the Health Research and Educational Trust, is designed to serve as a starting point for hospital leaders to assess, prioritize, implement, and monitor strategies to reduce avoidable readmissions. The guide is available as a PDF and requires Adobe Reader.

The Aging Network and Care Transitions: Preparing your Organization Toolkit

This toolkit was developed for health care provider organizations that are ready to prepare their organization for a role in care transitions programs. Many of the patients served by the Aging Network are considered high-risk for multiple hospital readmissions and the accompanying health complications.

Transition Coaches Reduce Readmissions for Medicare Patients With Complex Postdischarge Needs

Developed by the Care Transitions Program at the University of Colorado at Denver and AHRQ, this Solution addresses managing Medicare patients in the process of discharge to reduce readmissions. By implementing the Care Transitions Intervention program, a coach helps patients in transition from hospital to home to take an active role in their post-discharge care. As a result of implementing this program, hospitals experienced reduced readmissions and costs. This Solution requires a web browser, and Adobe Reader to view the PDF document.

Re-Engineered Discharge (RED) Toolkit - Updated Version

Researchers at the Boston University Medical Center (BUMC) developed the Re-Engineered Discharge (RED) and it was effective at reducing readmissions and emergency department (ED) visits. The Agency for Healthcare Research and Quality (AHRQ) contracted with BUMC to develop this new toolkit to assist hospitals, particularly those that serve diverse populations, to replicate the RED. This toolkit is an enhancement of previous RED resources and introduces a new RED component on overcoming language barriers.

Identifying Potentially Preventable Readmissions

Hospital readmission rates may result from actions taken or omitted during the initial hospital stay and are an indication of the quality of patient care. Preventable readmission (PPR) methods are outlined in this paper and it addresses methods to identify potentially preventable hospital readmissions using computerized discharge abstract data. These methods will help to increase the quality of patient care; and could also compliment pay-for-performance incentives. The paper is available as a PDF and requires Adobe Reader to view it.

Implementation Guide for Readmissions

The Partnership for Patients purpose is to reduce readmissions by developing a more cohesive plan of care that is clearly communicated to the patient and family upon discharge. The main factors are medication reconciliation, communication handoff, post-discharge access and post-discharge plan of care. Their Evidence-Based Practice Guidelines based on the “Project Re-Engineered Discharge” intervention program. The toolkit is available as a PDF and requires Adobe Reader to view it.

NoCVA Readmissions Toolkit: Data Manual

The North Carolina-Virginia Hospital Engagement Network (NoCVA HEN) national initiative is to reduce patient harm and reduce readmissions. The resources and information in this manual addresses the collaborative metrics to assess level of performance by tracking key measures in order to: Focus efforts and ensure all team members are on the same page, Establish goals, track progress, and identify milestones, and Track how interventions are impacting outcomes. The toolkit is available as a PDF and requires Adobe Reader to view it.
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