Top Prevention Highlights

Advanced readmission bundle

• Advanced discharge planning: focuses on comprehensive, multidisciplinary team discharge planning from admission.
  • Use standardized best practices in:
    • Preventable Readmission Action Planning Guide
    • The Role of the Hospitalist in Reducing Readmissions
    • Improving Care Transitions
• Care partner project: an emerging area where evidence shows that implementation positively impacts readmission reduction, resource utilization and patient satisfaction.
  • Engage patient and care partner using the Care Partner Framework:
    • Care Partner Model: Commit, Identify, Include and Prepare
    • Care Partner Program Implementation Guide
    • Care Partner Program Implementation Checklist
• Readmission reduction through partnership with skilled nursing facilities project:
  • provide both verbal and written discharge plan to patient and care partner;
  • utilize tools and data:
    • Readmission Reduction Through Partnership with Skilled Nursing Facilities Toolkit;
    • SNF readmission data;
    • skilled nursing facility-to-hospital readmission — data abstraction tool;
    • patient and care partner interview tool: readmission from SNF;
    • circle back interview tool;
    • medication discrepancies data collection tool: for hospital-to-SNF transitions; and
    • understand the capabilities of emergency departments and observation status.
• Multiple-Admission Patient:
  • tools and toolkit — ASPIRE Framework;
  • data analysis to identify readmission patterns;
  • survey current readmission efforts; and
  • enhance services for high-risk patients.
• The value of diagnostic-specific readmissions:
  • develop an implementation guide;
  • tools and toolkit – use of disease-specific Gold Standards; and
  • use of PPR reports.