Getting Started: How to Improve

Learn about the Model for Improvement, forming the improvement team, setting aims, establishing measures, and selecting and testing changes. Go to How to Improve.

Reduce Avoidable Readmissions

Hospitalizations account for nearly one-third of the total $2 trillion spent on health care in the United States. In the majority of cases, hospitalization is necessary and appropriate. However, a substantial fraction of all hospitalizations are patients returning to the hospital soon after their previous stay. These rehospitalizations are costly, potentially harmful, and often avoidable.

Evidence suggests that the rate of avoidable rehospitalization can be reduced by improving core discharge planning and transition processes out of the hospital; improving transitions and care coordination at the interfaces between care settings; and enhancing coaching, education, and support for patient self-management.

Effective Interventions to Reduce Rehospitalizations: A Compendium of 15 Promising Interventions
This document highlights the range of effective programs underway to reduce avoidable rehospitalizations across the US.
Effective Interventions to Reduce Rehospitalizations: A Survey of the Published Evidence
This survey of the published literature regarding the effective interventions to reduce avoidable rehospitalizations revealed that the current body of published interventions fall into four broad categories.
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, with the related goal of reducing avoidable readmissions.
How-to Guide: Improving Transitions from the Hospital to Home Health Care to Reduce Avoidable Rehospitalizations
This How-to Guide is designed to support home health care improvement teams and their hospital and 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, with the related goal of reducing avoidable rehospitalizations.
How-to Guide: Improving Transitions from the Hospital to Skilled Nursing Facilities to Reduce Avoidable Rehospitalizations
This How-to Guide supports teams in skilled nursing facilities (SNFs) and their community partners in codesigning and reliably implementing improved care processes to ensure that residents have a safe and effective transition into the SNF, with the related goal of reducing avoidable readmissions into the hospital.
How-to Guide: Improving Transitions from the Hospital to the Clinical Office Practice to Reduce Avoidable Rehospitalizations
This How-to Guide is designed to support office practice-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 back to the care team in the office practice, with the related goal of reducing avoidable readmissions.

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WIHI: Lowering Readmissions, Reducing Disparities

October 25, 2018 | Initiatives to reduce avoidable readmissions are the norm in US health systems today. What happens when hospitals and health systems look beyond to the non-clinical issues upstream that have a big impact on rehospitalizations?
Visiting Nurse Service of New York's Choice Health Plans: Continuous Care Management for Dually Eligible Medicare and Medicaid Beneficiaries

This case study describes how a large nonprofit home health care provider created health plans to serve the dually eligible Medicare and Medicaid population, and how its customized care management approach led to reductions in hospitalizations and readmissions.
Gaining Ground: Care Management Programs to Reduce Hospital Admissions and Readmissions Among Chronically Ill and Vulnerable Patients

Preventable hospital admissions and readmissions are indicators of health system fragmentation associated with suboptimal patient outcomes and avoidable costs of care. This synthesis report looks at three case studies that illustrate the potential of care management programs to address this problem by improving care coordination and transitions among high-risk patients.

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