Effective communication and collaboration stand as the linchpins in the effort to diminish rehospitalization. Research indicates that a united front involving healthcare professionals, such as physicians, hospital leadership, and administrators in assisted living or skilled nursing facilities, can prevent unnecessary and costly readmissions when working in tandem.

While predicting individuals at risk for readmission remains an imperfect science, healthcare professionals have been addressing specific concerns, including:

  • Feeling unprepared for discharge
  • Difficulty performing activities of daily living
  • Trouble adhering to or accessing discharge medications
  • Lack of social support

Here are 10 strategies aimed at reducing hospital readmissions: 

  1. Prioritize quality care, leading to decreased readmission rates, improved performance on quality measures, and realized savings.
  2. Initiate care management and discharge planning early, maintaining open communication across the care team, including family members, primary care providers, and facility staff. Schedule post-discharge follow-up appointments and conduct phone calls soon after discharge for ongoing assessment and addressing questions.
  3. Conduct face-to-face reviews of medications, with physicians providing clear, explicit instructions on proper usage.
  4. Employ teach-back techniques to ensure patient education, tailoring information to the patient’s level of understanding and asking them to explain the given information.
  5. Utilize health information technology to facilitate the handoff from inpatient to outpatient settings, allowing primary care physicians quick access to relevant hospital information.
  6. Implement enhanced training for staff in assisted living and skilled nursing facilities, focusing on early identification and addressing changes in residents’ health and mental/functional status.
  7. Introduce “SNFists” – on-site physicians, nurse practitioners, or physician’s assistants for immediate assessments of changes in clinical status, preventing unnecessary hospitalizations.
  8. Explore community paramedicine, especially in rural or underserved areas, enabling paramedics to expand their services to provide home visits and health services to at-risk patients.
  9. Emphasize advance directives, documenting and filing patients’ end-of-life care preferences to guide treatment decisions during healthcare status changes.
  10. Integrate palliative care and hospice for eligible patients, offering a dignified and comfortable alternative to frequent hospital visits. A hospice team manages pain and symptoms while providing social, emotional, and spiritual support to patients and their families in various settings, including private residences, assisted living communities, or skilled nursing facilities.
“Collaboration and communication between hospitals and nursing homes/assisted living homes is important to reduce readmissions. I have seen firsthand how these partnerships can not only reduce readmissions, but the relationships built between the partners in these organizations. This improves trust and communication,” shared Tammy Wagner, Great Plains QIN Quality Improvement Advisor. Tammy Baumann Headshot

GPQIN Tools & Resources:

Teach-Back Training Materials:

Teach-Back Training Video (6 minute tutorial)
Teach-Back: ‘How to Get Started’ Presentation (to accompany video)

State Reports:

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Multi-Visit Patient (MVPs) – Reducing Preventable ED Visits

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Reducing Avoidable Emergency Department Visits

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