Research shows that, on average, 20 percent of patients in the U.S. are readmitted to a hospital within 30 days of discharge. While patients are readmitted to address medical issues, some readmissions are avoidable. For example, underlying social and behavioral factors may exacerbate medical conditions if left unaddressed. A new approach is needed to provide whole person transitional care to our patients most vulnerable to readmissions. This patient-centered approach focuses on identifying high-risk patients, understanding the contextual factors contributing to health and warm handoffs to community support.
Getting Started
Whole person transitional care requires coordinated effort to identify, engage and follow-up with patients leaving the hospital setting.
Measure Readmissions
Track volume and frequency of readmitted patients at your facility. Data is available through WSHA based on hospital discharge data. Your individual report will display all-cause readmissions count by month benchmarked to similar facilities in Washington State.
Engage Multi-Visit Patients
Four or more hospital admissions in a 12-month period denote “multi-visit patients” (MVPs). These patients are likely experiencing medical, social and behavioral challenges. Building on the AHRQ ASPIRE toolkit, teams can learn to flag patients in real-time, engage in conversation to detect underlying contributors to readmission and link to resources. Join a cohort to learn from others implementing this model in the Pacific Northwest Region.
Establish Partnerships in the Community
Screening patients for social determinants of health (transportation, food insecurity, housing, etc.) will identify barriers which may lead to poor outcomes. Warm handoffs are needed to build a sense of trust and rapport with providers and community resources outside of the hospital setting. Conduct a Health Equity Organizational Assessment to understand how patient social and demographic data at your facility can inform your work.
Toolkits & Resources
WSHA Toolkits
This toolkit includes a collection of resources, checklists and insights from health facilities engaged in readmissions quality improvement projects.
- WSHA Reducing Readmissions: Care Transitions Toolkit 3rd Edition
Developed by the WSHA Readmissions Workgroup, adapted from Pierce Co. and KC4TP Warm Handover Guide. This form can be used to support handoff between hospital and SNF staff.
- WSHA Tool 14: Hospital to SNF Warm Handover Guide
Additional Resources
Agency for Healthcare Research and Quality (AHRQ)
- ASPIRE Toolkit: Designing and Delivering Whole-Person Transitional Care
- AHRQ Re-Engineered Discharge (RED) Toolkit
For assistance detecting and exploring the root cause of readmissions health disparities, review the CMS Guide to Reducing Disparities in Readmissions.
Consider refresher training for transition staff using the Teach-back Training technique.
