How to maximize the Readmission Reduction Toolkit

To get the most out of the Readmission Reduction Toolkit, you’ll need to know who should use it, how to use it, and how to track your progress.

We've made getting the answers to these questions easy. Review the frequently asked questions below to make sure you have the right team and goals in place before you dive in.



 Who should be involved in readmission reduction strategy development?

The practices in the toolkit will require involvement from a wide range of individuals across your hospital. If you haven’t already, consider creating a readmission reduction task force to engage important stakeholders and ensure everyone is aligned in this mission. Use the toolkit to guide discussions during task force meetings, beginning with the FAQs and progressing through each stage of the toolkit.

Potential stakeholders include:

  • Chief medical officer
  • Cardiovascular service line administrator
  • Cardiovascular service line medical director
  • Director of pulmonology
  • Director of case and/or care management
  • Physician representatives from relevant specialties (e.g., cardiology, primary care, HF experts)
  • Nurse managers and/or directors of inpatient units caring for HF, AMI, pneumonia patients
  • HF clinic leadership
  • Representatives from post-acute care facilities (e.g., SNF, long-term acute care, home health)

 Who should use the toolkit?

The four stages of the toolkit address different aspects of patient care across the continuum, so leaders should carefully evaluate who should work on each stage. We’ve provided suggestions below, but this may vary by institution. 

Stage 1: Admission nurses, case management team, director/nurse manager of inpatient units

Stage 2: Nurse manager of inpatient units, director of patient education, patient and family advisory council leaders

Stage 3: Director of ambulatory strategy, director of post-acute care, PCPs, transitional care directors/coordinators

Stage 4: Case management team, transitional care directors/coordinators, directors of HF clinics


 How do I identify where my institution’s readmission strategy needs improvement?

We’ve mapped some common challenges to relevant sections of the toolkit, and you can select those that apply to you. While we recommend reviewing the entire toolkit to ensure you’re developing a comprehensive readmission reduction strategy, this tool will help you focus your efforts where they'll have the most impact. We recommend completing it as a team to spark discussion and thorough analysis of performance improvement opportunities.


 How should I determine my readmission reduction goal?

There is no standard for a few reasons. First, all hospitals would have to be starting from the same (or at least similar) readmission rate, which is not the case. Hospitals with very high readmission rates have more room for improvement, while hospitals with lower readmission rates have less room for improvement. In addition, each hospital has different characteristics that could make its readmission reduction goals different. These include:

  • Case mix index
  • Volume
  • Payer mix
  • Geographic location
  • Resources 
  • Executive support
  • Staff buy-in
  • Alignment with physicians

Although there is no perfect method for determining your annual readmission reduction goal, hospitals can and should set reasonable targets. Here is some advice on how to go about setting a percentage goal rate for readmissions.

Set a baseline rate: If you have been tracking readmission rates in a consistent fashion, first determine what the year-to-year changes have been. This will give you an understanding of the typical variation.

Agree on a consistent definition: It's also important to note that there are several different ways to track readmission rates (as shown in the chart below), so make sure that what you intend to track is consistent. For example, will you be tracking all-cause 30-day readmissions that occur hospital-wide? Or will you be narrowing the definition to 30-day readmissions for HF patients?

Set a realistic, but ambitious goal: Once you've established a consistent definition and developed a methodology for tracking this data, you can begin to think about setting an improvement target relative to your current baseline. There are a few different ways to think about this:

  • Attainable improvement rates: An arbitrary, low number that is reasonable to achieve in a given year, but that is statistically significant enough to account for regular fluctuations. These goals could also be called "conservative" or "realistic."
  • "Stretch goals": An ambitious target that would require more immediate and aggressive decreases in readmission rates. The benefit to this type of goal is that it pushes the organization beyond what it thought possible; however, failing to meet the stretch goal could demoralize staff.
  • Comparison to control group: A comparison of readmission rates for a particular patient population pre- and post-intervention. 

 How should I track my progress?

While readmission reduction is the end goal, there are incremental metrics you can track along the way to ensure you're maximizing the value of the tools and practices and using them appropriately. We’ve outlined some suggested metrics you can monitor as you work through each stage in the toolkit.

Stage 1: Transition Planning During the Inpatient Stay

  • Percentage of patients receiving a readmission interview or questionnaire at the time of admission
  • Number of systems-related issues identified through readmitted patient interviews
  • Percentage of patients who are screened for psychosocial issues
  • Percentage of patients receiving a risk stratification assessment on day one of their inpatient stay
  • Percentage of patients whose transition planning discussions are being initiated on day one of their inpatient stay

Stage 2: Improving Patient Education and Activation During Hospitalization

  • Average level of completion of educational materials intended for review during the inpatient stay
  • Percentage of patients receiving teach back or similar patient-directed education
  • Percentage of patients/family caregivers completing patient compacts

Stage 3: Coordinating with Post-Acute Care Services and Providers

  • Percentage of patients receiving appropriate referrals to palliative care
  • Percentage of providers trained on appropriate selection of post-acute care setting
  • Percentage of patients discharged to a post-acute care facility that are readmitted back to the hospital
  • Number of complaints from PCPs regarding unclear post-discharge instructions
  • Frequency of hospital/post-acute care provider discussions regarding failed transfers and other transition-oriented processes

Stage 4: Providing Intensive Transitional Care Support

  • Percentage of patients receiving follow-up phone calls within designated amount of time based on risk (e.g., within 48 hours of discharge)
  • Percentage of high-risk patients assigned to care transition coordinator
  • Percentage of high-risk patients referred to home visit or high-risk clinic

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