HEN Readmissions Main
The following guide, developed by quality managers throughout the state, provides a step-by-step method for addressing and preventing readmissions. It can be used with an all-cause readmission improvement effort or one focused on a particular at-risk patient, such as cardiac patients.
There are two parts to the guide. The first is focused on initiatives a hospital can do on its own. The second part suggests ways to work with external partners to affect some of the external reasons for readmission.
Linked throughout the guide are tools and information to provide quick references for program components and how-to’s for getting started. While there are examples for each phase of the improvement work, we have not provided an exhaustive list, and you will probably want to tweak the tools to fit your hospital. Please note, if you have any tools to share, please email them to firstname.lastname@example.org.
Internal Readmissions Work
Developing your Plan - Suggestions for team members, identifying problem areas, developing strategies and testing changes
Step-by-Step Guide - Tips for working with at-risk patients from admission through discharge
Step 1 - Performing a risk assessment - Instructions for using LACE for screening of all patients and 8 Ps for more indepth look at high risk patient
Step 2 - Developing patient-specific interventions
Step 3 - Discharge planning
Step 4 - Post-discharge transitions and follow up
Other Readmissions toolkits:
In addition to the items we've highlighted on this site, there are numerous guides available for reducing readmissions. Some of these are listed below: