Readmission rates are increasingly seen as markers of local health care systems’ ability to coordinate care for patients leaving the hospital. Research shows that 20 percent of patients in the United Sates are rehospitalized within 30 days of discharge. 

While some readmissions are necessary and appropriate, up to 76 percent of these readmissions are potentially avoidable for a variety of reasons, according to an analysis conducted by the Medicare Payment Advisory Committee (MedPAC). Poorly executed transitions in care negatively affect the patient’s health and well-being, family resources, and unnecessarily increase the costs incurred by the health care system. A systematic review of studies on interventions to reduce readmissions concluded that the most promising interventions were those that concentrate on coordination and communication around the time of discharge.


Implement reducing readmission bundle elements for all AMI, Heart Failure, and Pneumonia patients, linking hospital with community. Bundle includes:

  1. Plan for follow-up care
  2. Current medication list
  3. Documentation of use of “teach-back” methodology
  4. Post-discharge follow-up call

Develop and test a standardized patient assessment and transitioning process between hospital and SNF settings that can be used both regionally and nationally to reduce readmission rate. 

  1. Identify and standardize what information set SNF providers need and how it will be transferred.
  2. Developed standard information set will be tested at the LEAPT hospitals and revised using the PDSA (Plan/Do/Study/Act) cycle.
  3. Spread the standard guidelines and replicate the change in other parts of the region. Review readmitted cases together with SNF on why patients are being readmitted and collaborate to address the issues.


Measuring Results

  • Readmission (effective transition): Percent of all-cause SNF readmissions discharged from and readmitted to hospitals within 30 - days
  • Numerator: Total number of all-cause SNF readmissions to the hospitals within 30 - days
  • Denominator: Total number of patients discharged to a SNF from the hospitals


Additional Resources


Amber Theel
(206) 577-1820