Readmissions are a costly and complex problem that require multiple strategies and ongoing efforts to reduce.   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.

Doctor talking to patient

Getting Started

Join WSHA’s Readmissions Roundtable

Beginning in March 2021, WSHA will host a bimonthly virtual roundtable to tackle readmission reduction in hospitals.  Sessions will be on the 2nd Tuesday of the odd months at 1 pm Pacific.  The roundtable will be a combination of didactic teaching about readmissions reduction strategies, review of readmissions data in the region, and information sharing/networking with facilities working on this initiative!  Register online here

Measure and Track Readmissions

WSHA is launching a new interactive readmissions dashboard soon! Track volume and frequency of readmitted patients at your facility. Data will be available through WSHA using hospital discharge data. Your individual hospital report will display all-cause and condition-specific 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

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.

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.  Hospital to SNF Warm Handover Guide

Consider refresher training for transition staff using the Teach-back Training technique.

For information about the availability of auxiliary aids and services, please visit:


Contact Us

Washington State Hospital Association
999 Third Avenue
Suite 1400
Seattle, WA 98104

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206.281.7211 phone
206.283.6122 fax

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