Iowa Healthcare Collaborative

Readmissions and Care Coordination


HRET Top Ten Checklist for Readmissions (PDF)
A checklist to review current interventions or initiate new ones to prevent avoidable readmissions in your facility. 

HRET Readmission Change Package 2017 (PDF)
This change package is intended for hospitals participating in the Hospital Improvement Innovation Network (HIIN) project led by the Centers for Medicare & Medicaid Services (CMS) and Partnership for Patients (PFP); it is meant to be a tool to help you make patient care safer and improve care transitions. This change package is a summary of themes from the successful practices of high performing health organizations across the country. It was developed through clinical practice sharing, organization site visits and subject matter expert contributions. This change package includes a menu of strategies, change concepts and specific actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care. This change package is intended to be complementary to literature reviews and other evidence-based tools and resources.

AHA HRET Hospital Engagement Network - Resources
Resources to drive improvement in preventable readmissions.

IHI Effective Interventions to Reduce Rehospitalizations
This document is intended to provide a sampling of the range of effective programs underway to reduce avoidable re-hospitalizations across the US. The 15 programs highlighted in this document are all very promising approaches to improve patient care. For purposes of clarity, the programs that have documented, peer-reviewed evidence of success in reducing re-hospitalizations are distinguished from other programs with less rigorous levels of evidence available to date.

Lace Tool (PDF)
A strategy, promoted by the Institute of Health Improvement, is to utilize a risk stratification tool to identify preventable readmissions. The “LACE” index is one such tool that is widely used.
The LACE index identifies patients that are at risk for readmission or death within thirty days of discharge. It incorporates four parameters.
• “L” stands for the length of stay of the index admission.
• “A” stands for the acuity of the admission. Specifically, if the patient is admitted through the Emergency Department vs. an elective admission.
• “C” stands for co-morbidities, incorporating the Charlson Co-Morbidity Index.
• “E” stands for the number of Emergency Department visits within the last 6 months.

Society of Hospital Medicine - Follow-Up Appointments Project BOOST Implementation Toolkit
Project BOOST — SHM’s signature mentored program — serves as a national model for improving the quality of care and reducing hospital readmissions. Project BOOST has also been recognized by the Centers for Medicare & Medicaid Innovation (CMMI) as an evidence- based approach to reducing readmissions. In addition to achieving reductions in unnecessary readmissions, some sites report increased patient satisfaction and improved length of stay in the hospital. Currently, more than 180 hospitals participate in Project BOOST, over 1,000 health care professionals participate on its active Listserv and more than 5,000 people have downloaded the original Project BOOST Implementation Guide and Toolkit.

Teach-Back Quick Start Guide (PDF)
Teach back is a method, utilized by healthcare providers, to confirm they have explained healthcare information in a manner understood by their patients.  

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