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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  

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

External Readmissions Initiatives - Working with the community

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: