“We’ve noticed that a lot of groups in the state are working toward the same goal and doing different things. One of our focuses is to bring groups together and leverage value where we can. There’s a need to share best practices, measure activities and make changes. There’s no shortage of activity.” –Summer Boslaugh, Program Manager, Quality Corp

While some hospital readmissions may be needed and appropriate, many are considered unnecessary or avoidable, and serve as indicators of poor care, poor coordination of care and/or inefficient use of health care resources.

That’s why hospitals, ambulatory care providers, community health centers and other state and local agencies are working together in Aligning Forces for Quality to improve health care quality and reduce readmissions. Lessons Learned in Performance Measurement: A Community's Approach to Reducing Readmissions, presents hospitals' strategies in three communities to help patients successfully transition from hospital care to home and reduce readmissions.
The strategies to reduce hospital readmissions range from patient level interventions to changes in the way providers are paid:

• Care coaches for patients with high likelihood of readmission
• In-home visits following hospitalization by nurses and other professionals to ensure appropriate follow-up and medication adherence
• Use of risk-stratifying tools to identify patients with high likelihood of readmission
• Use of educational materials adapted to appropriate literacy levels
• Payment reforms to incentivize providers to reduce readmissions
• Use of standardized discharge care planning