Reducing Readmissions

Maintaining continuity in patients' medical care is critical following discharge from the hospital to ensure successful recovery. Poor coordination of care across settings can result in costly, potentially harmful, and often avoidable re-hospitalizations. Poor care transition, failures in communication between providers, lack of patient and family involvement and few standardized tools and processes can all contribute to adverse events or avoidable readmissions. Evidence suggests improving core discharge planning and transition processes out of the hospital may reduce the rate of avoidable re hospitalizations.

The materials in this toolbox outlines best practices and provides easy-to-use tools and resources to help hospitals improve or redesign care processes to reduce avoidable hospital readmissions that occur within 30 days of discharge.

Tools and Links

The "Always Use Teach Back!" tools can be used to confirm patient understanding of care instructions by asking patients to repeat the instructions using their own words. An extensive suite of tools is available for download, and more information is available at

Hospitalizations account for nearly one-third of the total $2 trillion spent on health care in the United States. In the majority of cases, hospitalization is necessary and appropriate. However, a substantial fraction of all hospitalizations are patients returning to the hospital soon after their previous stay. These rehospitalizations are costly, potentially harmful, and often avoidable.

Evidence suggests that the rate of avoidable rehospitalization can be reduced by improving core discharge planning and transition processes out of the hospital; improving transitions and care coordination at the interfaces between care settings; and enhancing coaching, education, and support for patient self-management. Check out these Readmission Resources.