Readmissions and Hospitalizations

The Network, in accordance with the Centers for Medicare & Medicaid Services (CMS), is working to improve care transitions and reduce ESRD-related hospitalizations, readmissions, and emergency department visits.

Please use these tools to improve care transitions and reduce hospitalizations in your facility:

HSAG RCA 5-whys Worksheet (PDF)

HSAG PDSA Worksheet (PDF)

Hospitalizations Tracker (Word Document)

Best practices shared by facilities that have decreased their hospitalization rates include:

• Tracking data at a facility level to identify trends and issues that need to be addressed (i.e., an increase in bloodstream infections).
• Tracking and trending data on an individual patient level, so patients who are at risk for hospitalization can be identified and focused interventions can be implemented.

Dialysis facilities can use the Hospitalizations Tracker to track and trend patient admissions and the follow-up needed.

Take Charge of Your Health: Reduce Unnecessary Hospitalizations Booklet
Your ESRD • Your Care • Your Priority (PDF)

Provides practical and relevant information on how patients can protect themselves against the need for unnecessary hospitalizations. Click on your Network-specific version below:

• Network 7
• Network 13
• Network 15
• Network 17

You can also share the following stand-alone handouts with patients. They are taken from the Take Charge of Your Health: Reduce Unnecessary Hospitalizations booklet and concentrate on a primary topic with an emphasis on working as a team.

• Sit Down—Don't Stand: Questions About You
• We're Not Being Nosy—We Care! (English)
• We're Not Being Nosy—We Care! (Spanish)
• Communication TIPS for Earning a WIN
• Play Offense—Avoid Hospitalization