A Community's Approach to Reducing Readmissions

As part of AF4Q, hospitals, ambulatory care providers, community health centers and other state and local agencies are working together to improve quality and reduce costly hospital readmissions. Most of the AF4Q’s 16 Alliances indicated efforts to report readmission rates as one of their key strategies for addressing cost and efficiency. Rates of hospital readmission are important outcome measures for assessing the performance of the health care system. While some hospital readmissions may be necessary 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. Regardless of the cause, unplanned hospital readmissions in the United States are frequent and costly. Reducing hospital inpatient readmissions is a key strategy for improving health care quality while reducing costs.

Lessons Learned from AF4Q: Common Strategies for Reducing Hospital Readmissions
• 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
 

View the full Lesson Learned piece here.