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The Healthcare Intelligence Network's ReadmissionsRx


CMS and private payors are closely scrutinizing hospital readmission rates and will soon penalize hospitals for certain avoidable hospital readmissions.

HIN's ReadmissionsRx is your source for reducing avoidable hospital readmissions. Get the latest on discharge planning, embedded case management, care transitions management, home visits at hospital discharge and medication reconciliation and other tactics to decrease the number of avoidable hospital readmissions. Sign up today to receive ReadmissionsRx twice monthly!

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Strategies and News on
Reducing Hospital Readmissions

Audio Interview

Josh Luke With hospital readmission rates under close scrutiny by CMS, Torrance Memorial Health System launched a readmission program in early 2013 that has been recognized as a program of excellence for its innovation and impact on the community. Navigators work with patients prior to discharge from the hospital to educate them on the hospital's Care Transitions program, which includes a network of Skilled Nursing Facilities, or SNF's and one home health agency. And once the patient is discharged, ambulatory case managers keep watch on the patients after the 30-day penalty phase is over.

Length: 12:55
Click here to listen

Recent Audio Interviews on
Hospital Readmissions

Assessing Re-admission Risk To Prioritize Home Visits for Complex Patients Click here to listen.

Patient Engagement and Provider Collaborations Across the Healthcare Continuum to Improve Care Transitions Click here to listen.

Care Transition Management: Strategies for Effective Patient Handoffs Click here to listen.

Care Coordination for Dual Eligibles: A Results-Oriented Approach Click here to listen.

Reducing Avoidable Medicaid ER Visits With a Community Partnership Approach Click here to listen.

Dr. Maria Lopes: Geisinger Reduces All-Cause 30-Day Readmission Rates Through Remote Monitoring Program Click here to listen.

Melanie Matthews: Second Annual Benchmarks in Reducing Avoidable ER Use — Pain Management Driving 'Ultra Utilizers' Click here to listen.

Dr. Mina Chang: Reducing Avoidable ER Visits by Medicaid Patients Through Quality-Based Interventions Click here to listen.

Dr. Stuart Levine: Reducing Readmissions Through Multi-Disciplinary Post-Discharge Support Click here to listen.

Carolyn Holder: Improving Transitions of Care Between Hospital and SNF — A Collaboration Supporting the Accountable Care Vision Click here to listen.

Susan Shepard: A Coordinated Discharge Planning Approach to Reduce Avoidable Hospital Readmissions Click here to listen.

Dianne Feeney and Dr. Randall Krakauer: Aligning Reimbursement To Reduce Avoidable Hospital Readmissions Click here to listen.

Mary Cooley: Reducing Avoidable Hospital Readmissions: A Case Study from Priority Health Click here to listen.

Doreen Salek: Constructing Care Transitions to Reduce Hospital Admissions Click here to listen.

Dr. Randall Williams: Reducing Heart Failure Admissions through Remote Health Monitoring Click here to listen.

Q and A: The Difference Between Inpatient Care Coordination and Case Management

This week's expert is Mary M. Morin, RN, NEA-BC, RN-BC, nurse executive with Sentara Medical Group

Question: What is the difference between inpatient care coordinator and case management?

Response: (Mary M. Morin) I use the term 'care manager.' I started with 'care coordinator' to align with inpatient, but in the medical group everyone does care coordination, so I changed this to 'RN care manager' to make the distinction between management vs. coordination. The inpatient care coordinators' management of patients is episodic and designed to move the patient through the hospital stay, whereas the care managers in SMG have established long-term relationships with patients and follow through all transitions. The health plan has case managers (RNs) but their role is insurance-based and claims-based, and their outreach is telephonic and focused on disease management to reduce costs and utilization.

Excerpted from Hybrid Embedded Case Management: New Model for Cross-Continuum Care Coordination.

View and Comment on Blog Posts
on Hospital Readmissions


Infographic: Reducing Readmissions for Value-Based Healthcare

Infographic: Reducing Readmissions for Value-Based Healthcare

Video: How to Reduce Hospital Readmissions


Produced: 2011

Strategies to reduce hospital readmissions, based on responses to the Healthcare Intelligence Network survey on Reducing Hospital Readmissions with commentary by HIN VP Melanie Matthews and Mary Cooley, manager of case and disease management at Priority Health.

Download Free Hospital
Readmissions White Paper

Reducing Readmissions in 2014: Post-Acute Partnerships Foster Collaboration Across Continuum

Comprehensive Hospital Readmission Resources

2014 Healthcare Benchmarks: Reducing Hospital Readmissions documents the latest key initiatives and partnerships to reduce readmissions by patients with heart failure, pneumonia, myocardial infarction, and other costly conditions by more than 100 healthcare organizations.

Guide to Dual Eligibles Care Coordination: Population Health Management for Medicare-Medicaid Beneficiaries provides the principles of a comprehensive care coordination effort for Medicare-Medicaid beneficiaries, taking into account the medical, behavioral, social and functional needs of this vulnerable population.

2013 Healthcare Benchmarks: Care Transitions Management, now in its third year, presents actionable new data on key transitions addressed, targeted health conditions and populations, care transition models in use, program components, responsibility for care transition coordination, transition team training, challenges, results, ROI, and much more.

Rethinking Readmissions: Patient-Centered Collaborations in Care Transition Management examines the data analytics driving the CMS Care Transitions Demonstration Project as well as some home-grown programs that are supporting patients' seamless transitions back into their communities.

Click here for additional readmission avoidance resources
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