An unplanned hospital readmission within 30 days of discharge often signals a breakdown in the transition between care settings or to home. Readmissions that occur within the first seven days are especially concerning, as many can be linked to gaps in discharge planning, communication, medication management, and timely follow-up care. These avoidable readmissions can negatively affect patient outcomes, increase costs for patients and the healthcare system, and create additional stress for patients and families. As a result, readmission rates are closely tracked by CMS as an important measure of care quality and care transition effectiveness.
The following evidence-based strategies, tools, and interventions can help strengthen care transitions, reduce avoidable readmissions, and improve patient outcomes.
Source: www.cms.gov/medicare/quality/value-based-programs/hospital-readmissions
- Teach-Back Tools
- Teach-Back Starter Sentences (HSAG)
- Teach-Back Guide for Staff (AHRQ)
- Teach-Back Quick Guide for Staff (AHRQ)
- Modified LACE Tool (HSAG)
- Bulletin: Reducing Nonurgent Emergency Department (HHS)
- Age-Friendly Health System (IHI)
For Patients/Residents and Families
- Patient and Family Education (HSAG)
- Zone Tools (HSAG)
AHRQ = Agency for Healthcare Research and Quality | HHS = U.S. Department of Health and Human Services | HSAG = Health Services Advisory Group | IHI = Institute for Healthcare Improvement
- The Roadmap to Success: Hospital Readmissions (HSAG)
- 30-Day Readmission Audit Workbook (HSAG)
- 7-Day Readmission Audit Tool Instructions (HSAG)
- Readmission Interview Tool (HSAG)
- Social Determinants of Health That Affect Your Patients (HSAG)
- Nursing-Led Transitional Care Model (University of PA)
- Improving Transitions from the Hospital to the Clinical Office Practice to Reduce Avoidable Rehospitalizations (STAAR)
For Patients and Families
HSAG = Health Services Advisory Group | STAAR = State Action on Avoidable Rehospitalizations
- Interventions to Reduce Acute Care Transfers (INTERACT) (Pathway Health): Create a free account at pathway-interact.com to access the following tools
- Quality Improvement Tools (Tracking Tools, Root Cause Analysis Tools)
- Communication Tools (Stop and Watch, SBAR, Tools to Communicate with Hospitals)
- Decision Support Tools (Acute Change in Condition File Cards, Care Paths)
- Advance Care Planning Tools (Tracking Tool, Resident and Family Education Tools)
- Best Practices to Reduce Preventable Readmissions (HSAG) (Coming Soon)
- Resident and Family Conversation Guide: In-House Treatment versus Hospital Transfers (HSAG) (Coming Soon)
