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- Preface, Disclaimers
- Table of Contents – by section
- The Issues
- Definitions
- Drivers to create innovative changes
- Major Quality Indicators
- Patient characteristics associated with unplanned readmissions
- NCQA HEDIS® measures for readmission rates
- Strategies to reduce unplanned or avoidable readmissions
- Advanced Directives
- Health Coaches
- Hospitalists; Medical Extensivists
- Translation/Language Interpreters
- Walk-in Clinics/Urgent Care Centers
- ER care issues may increase hospital readmissions
- Discharge issues
- Discharge dictation – prompt overnight transmission to all providers
- Health plan focus on readmissions and preventable adverse events
- Care Coordination/Transition of Care Management
- Long-term Care/SNFs
- Re-engineered discharge project reduces return trips to the hospital
- SBAR
- A Healthier Population … – example program links
- Hand-offs or Sign Outs – Managing the Care Transition
- Case or Care Management
- Readmission Monitor Data Collection Tool
- Home Care
- Homebound program
- Target the Targets – Target the CMS Targeted Readmissions
- Heart Failure: Readmission Issues/Process of Care Recommendations; Resources
- Acute Myocardial Infarction: Process of Care Recommendations; Resources
- Pneumonia: Issues, Recommendations, Resources
- Nosocomial or Iatrogenic Infections
- Stroke
- Addendum
- Never and Avoidable Events – Hospital issues, Health plan policy and resources
- 30 day readmissions – Health plan policy and resources
- References and Resources
- Apollo publication list
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