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Top Prevention Highlights

Preventable readmissions evidence-based practices and top prevention techniques

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.