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Health Care Leader Action Guide to Reduce Avoidable Readmissions

Reducing avoidable hospital readmissions is an opportunity to improve quality and reduce costs in the health care system. This guide is designed to serve as a starting point for hospital leaders to assess, prioritize, implement, and monitor strategies to reduce avoidable readmissions.

Steps for hospital leaders to reduce avoidable readmissions
Recognizing that hospitals may be at different points in the process, this guide follows a four-step approach to aid hospital leaders in their efforts to reduce avoidable readmissions. The four steps are:

  1. Examine your hospital's current rate of readmissions.
  2. Assess and prioritize your improvement opportunities.
  3. Develop an action plan of strategies to implement.
  4. Monitor your hospital’s progress.

Major strategies to reduce avoidable readmissions
This guide is meant to address readmissions that are avoidable and not all readmissions. Many readmissions, in fact, could represent good care; such as those that are part of a course of treatment planned in advance by the doctor and patient, or readmissions that are done in response to trauma or a sudden acute illness unrelated to the original admission. Neither public policy nor hospital actions should deter these readmissions from occurring. Instead, this guide is meant to better equip hospitals to address the readmissions that are unplanned and potentially the result of missteps in care either during the hospitalization or in the period immediately following the hospitalization. Hospitals should focus on these potentially avoidable readmissions to see if they can act—or they can encourage others to act—in such a way as to reduce their occurrence. This document suggests strategies that hospitals could pursue at different stages of the care continuum to reduce avoidable readmissions.

The strategies on the tables below are the foundational actions in the different interventions to reduce avoidable readmissions.


Table 1: During Hospitalization

  • Risk screen patients and tailor care
  • Establish communication with primary care physician (PCP), family,
    and home care
  • Use "teach-back" to educate patient/caregiver about diagnosis and care
  • Use interdisciplinary/multi-disciplinary clinical team
  • Coordinate patient care across multidisciplinary care team
  • Discuss end-of-life treatment wishes

Table 2: At Discharge

  • Implement comprehensive discharge planning
  • Educate patient/caregiver using "teach-back"
  • Schedule and prepare for follow-up appointment
  • Help patient manage medications
  • Facilitate discharge to nursing homes with detailed discharge instructions and partnerships with nursing home practitioners

 Table 3: Post-Discharge

  • Promote patient self management
  • Conduct patient home visit
  • Follow up with patients via telephone
  • Use personal health records to manage patient information
  • Establish community networks
  • Use telehealth in patient care

Publication Details



A. Osei-Anto, M. Joshi, A.-M. Audet et al., Health Care Leader Action Guide to Reduce Avoidable Readmissions, Health Research & Educational Trust, The Commonwealth Fund, and the John A. Hartford Foundation, January 2010.