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Readmissions Network

Network Overview

The Readmissions Network is convening community coalitions across the region in an effort to address the problems associated with reducing avoidable readmissions, increasing medication safety, improving patient satisfaction with discharge care and improving overall care coordination among health care providers. Specifically, our goals include reducing hospital readmission and admission rates in the Medicare program by 20 percent by 2019. View our fact sheet (PDF) for an expanded view of our goals.

A Community-Based Approach

To address these issues, we are focusing on processes of care at a community level to engage providers and stakeholders across the continuum of care, not just in the hospital. This includes home health agencies, dialysis facilities, skilled nursing facilities, pharmacies, Federally Qualified Healthcare Centers (FQHCs) and physician offices, as well as patients, families, payers and community stakeholders.

We are specifically working with communities that experience a high incidence of adverse drug events, a major contributing factor to high readmissions rates. Our goal is to work with communities across the region improving 30-day readmissions rates in communities where 60 percent of Medicare Fee-for-Service (FFS) beneficiaries live. In addition to medication safety, we will work with providers and stakeholders in the targeted communities focusing on the following Medicare populations:

  • Eligible for both Medicare and Medicaid
  • Multiple chronic conditions
  • Behavioral health issues, such as depression
  • Alzheimer’s and dementia
  • Lower socioeconomic status and other social determinants of health, such as lack of transportation or healthy food

Why Participate?

Our consultants work directly with you and your staff to implement solutions and interventions to bring about lasting change in your facility and community. In addition, you will work with industry experts to help identify areas for improvement, analyze root causes, develop action plans and implement evidence-based interventions that will improve care in your organization. The TMF QIN-QIO will act as a community factor, bringing stakeholders and providers from across the continuum of care together to collaborate, learn and work toward a common goal of improving patient care, reducing readmissions and building strong and lasting community partnerships.

The Readmissions Network offers a tremendous opportunity to position health care organizations for the future. By joining our network your organization receives:

  • Access to our data portal and quarterly 30-day readmission data reports for participating providers in recruited communities
  • Inclusion in an “all participate, all learn” collaborative with peer organizations
  • Structured exchanges of information in live, web-based and online formats
  • Free educational opportunities including conferences and webinars
  • Practical insight on the complexities of adapting interventions
  • Positive reinforcement of participants’ contributions gleaned from field experience and innovations
  • A relentless focus on finding new ways to help providers and creating value for you

Download this fact sheet (PDF) and view these videos to learn more about how your facility will benefit from joining the Readmissions Network.

Join the Readmissions Network

All providers are encouraged to join our network to achieve sustainable, measurable reductions in preventable readmissions and admissions for all patients. To join, click here to create a free website account and follow the prompts.

Partnering Organizations




Links to external sites are intended to be informational and do not have the endorsement of TMF Health Quality Institute. In addition, these sites may not be accessible to persons with disabilities.

Quick Links

Download these resources to learn more about the Readmissions Network.

Fact Sheet and Infographics

Network Videos

Community Charters

Data Portal


Number of new readmissions network members
Data as of Jan. 9, 2017.
Click to view larger image.

Growth of HHA participation in Readmissions network
Data as of Jan. 9, 2017.
Click to view larger image.

April 12 Webinar

Empowered Kidney Care

In this free TMF QIN-QIO webinar, Richard L. Gibney, MD, Central Texas Nephrology Associates, will discuss the "Empowered Kidney Care" program, an innovative approach to dialysis. Within the program, dialysis patients are experiencing a dramatic drop in hospitalization and mortality rates compared to conventional dialysis. This webinar will take place on Wednesday, April 12, noon - 1 p.m. CT. Register today.

May 2 Webinar

Immunization: Everyone's Responsibility

The next National Learning & Action Network event, hosted by the Quality Innovation Network National Coordinating Center, will cover working with communities to promote best practices of healthy living, a CMS Quality Strategy goal. Additionally, presenters will focus on strategies to effectively immunize Medicare beneficiaries and health care workers. This webinar will take place on Tuesday, May 2, 2 - 3:30 p.m. CT. Register today.

May 11 - 12 Summit

2017 Texas Primary Care and Health Home Summit

The 2017 Texas Primary Care and Health Home Summit will focus on expanding access to quality and person-centered primary care. Attendees will learn best practices for innovation in primary care and will have multiple opportunities to interact with program experts at various stages of implementation. The event will be May 11 - 12, at the Sheraton Gunter Hotel in San Antonio. Learn more and register today.

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