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Storyboards from IHI 14th Annual International Summit on Improving Patient Care in the Office Practice and the Community

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Storyboards of improvement work on display at IHI's 14th Annual International Summit on Improving Patient Care in the Office Practice and the Community are freely available for all registered IHI.org users to view.

Enhancing the Effectiveness Effectiveness of Follow-Up Phone Calls to Improve Transitions in Care: Three Decision Points

This study used a nonsystematic review of the literature focused on the use of telephone follow-up to improve postdischarge processes and reduce avoidable readmissions, and examined use of such calls among organizations participating in the STate Action on Avoidable Rehospitalizations (STAAR) initiative.

Storyboards from IHI's 24th Annual National Forum on Quality Improvement in Health Care

Storyboards of quality improvement work on display at the 24th Annual National Forum on Quality Improvement in Health Care in December 2012 are freely available for all registered IHI.org users to view.

Targeting Patient Transitions to Reduce Readmissions

The transition that takes a patient from the hospital to their home or another care setting marks a pivotal care moment. Zeroing in on what happens during this critical juncture, with the support of IHI’s STAAR initiative, has helped the Ohio Hospital Association make significant progress in its aim to reduce hospital readmissions by 20 percent within two years.

STAAR Issue Brief: The Effect of Medicare Readmissions Penalties on Hospitals’ Efforts to Reduce Readmissions

To understand the impact of the Medicare financial penalties for hospitals that have higher than expected rates of 30-day readmissions for select conditions, this Issue Brief synthesizes perspectives from leaders of state hospital associations, quality improvement organizations, and hospitals representing a range of performance and experiences in readmissions and their reduction.

IHI's Approach to Reducing Avoidable Rehospitalizations

This video will make the case for reducing avoidable rehospitalizations by creating a more patient-centered ideal transition home.

Reducing Avoidable Rehospitalizations: Getting Started with Creating an Ideal Transition from Hospital to Home

This video will review the steps to getting started on creating an ideal transition home for patients and families being discharged from the hospital, as part of overall efforts to reduce avoidable rehospitalizations.

Recasting Readmissions by Placing the Hospital Role in Community Context

The authors suggest that it is advantageous to view readmissions within a broader systems and community context that effectively engages all stakeholders to cooperatively improve outcomes.

WIHI: Reality Knocks with Reducing (Hospital) Readmissions

November 15, 2012 | This WIHI convenes important leaders and thinkers to talk about promising ideas and strategies for reducing avoidable hospital readmissions and improving care coordination.

How-to Guide: Improving Transitions from the Hospital to the Clinical Office Practice to Reduce Avoidable Rehospitalizations

This How-to Guide focuses on the reception of patients back into the office practice after hospitalization and is intended to be a resource for clinicians and staff in office practices as they create new ways to provide optimal care for their patients.

How-to Guide: Improving Transitions from the Hospital to Home Health Care to Reduce Avoidable Rehospitalizations

This How-to Guide is designed to support hospital-based teams and their community partners in creating an ideal reception into home health care in the first 48 hours after the patient is discharged from the hospital, a post-acute care setting, or a rehabilitation facility.

How-to Guide: Improving Transitions from the Hospital to Skilled Nursing Facilities to Reduce Avoidable Rehospitalizations

This guide focuses on the transfer of patients to skilled nursing facilities (SNFs), an umbrella term that includes nursing homes, long-term care facilities, acute rehabilitation facilities, and post-acute care facilities.

How-to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations

This How-to Guide is designed to support hospital-based teams and their community partners in codesigning and reliably implementing improved care processes to ensure that patients who have been discharged from the hospital have an ideal transition to the next setting of care.

Reducing Hospital Readmissions

Reducing avoidable hospital readmissions takes collaboration among a full range of health care settings and stakeholders beyond the "hospital walls," and requires understanding and attending to the experiences of patients over time, across settings.

Readmissions Diagnostic Worksheet

This diagnostic tool helps hospitals perform an in-depth review of the last five rehospitalizations to identify opportunities for improvement.

An Early Look at a Four-State Initiative to Reduce Avoidable Hospital Readmissions

The STate Action on Avoidable Rehospitalizations initiative (STAAR) has been successful in aligning numerous complementary initiatives within a state, developing statewide rehospitalization data reports, and mobilizing a sizable number of hospitals to work on reducing rehospitalizations.

WIHI: Breaking the Cycle of Readmissions

May 7, 2009 | For a significant number of patients, readmission to the hospital happens all too frequently — for costly reasons that could be better anticipated and avoided. There are ways to reduce readmissions, even in a notoriously fragmented health care system.

Rehospitalizations among patients in the Medicare fee-for-service program

This study finds that almost one-fifth of Medicare beneficiaries who are discharged from a hospital are readmitted within 30 days.

Improving transitions to reduce readmissions

In the hospital setting, poor coordination of care often results in hospital readmissions, many of which are avoidable.

Reducing Readmissions for Heart Failure Patients: Hackensack University Medical Center

Hackensack University Medical Center (Hackensack, New Jersey, USA) has dramatically reduced heart failure readmission by implementing telephone follow-up with patients.

Improving Heart Failure Care Through Education

At Advocate Health Care, based in Oak Brook, Illinois (USA), the Heart Failure team recognized that teaching patients how to self manage this chronic illness is vital to improved quality of life and can have a significant impact on readmission rates.

Kaiser Permanente: Where Patients Returning Home Receive Both Human and Technological Support

Transition nurses help smooth the transition home for congestive heart failure patients by remaining in contact for several weeks after discharge, and home telemonitoring helps patients manage their health. This dual approach has decreased hospitalization and readmission rates for heart failure patients.

St. Luke’s Hospital: Where Patients’ Home Care Needs Are Anticipated at Discharge

By providing self-management support for patients at home, St. Luke’s Hospital in Cedar Rapids, Iowa, part of the Iowa Health System, is reducing its rate of readmissions for heart failure patients.

Patient First: Efficient Patient Flow Management Impact on the ED

Memorial Regional Hospital (Hollywood, Florida, USA) improves care and service in the adult emergency department by focusing on key operational, clinical, and service improvement strategies.

WIHI: Reducing Readmissions, Restoring Revenues: Making Good Care Count

October 7, 2010 | This WIHI discusses why it’s critically important to make the financial impact of reducing readmissions a living, breathing, part of your quality agenda. Also discussed is the STAAR initiative, which is working with a courageous group of hospitals that are learning how to analyze their admissions (and readmissions) patterns with some new eyes and new thinking.

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