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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


Oct. 23 Event

Advancing Palliative Care in Texas Continuing Education Event

Register today for the Texas Health and Human Services Commission's event on Oct. 23, 1:30 - 3:30 p.m. CT. Session topics include Recommendations for the Texas Palliative Care Interdisciplinary Advisory Council and Having Conversations that Matter: Communication in Serious Illness. Participants can attend in person or virtually.

Oct. 25 Webinar

Delivering House Calls to Reduce Hospital Readmissions

Register today for this free TMF Quality Innovation Network webinar on Oct. 25, 2017, noon - 1 p.m. CT, to learn how HealthStar Physicians of Hot Springs, a health care practice management company in Arkansas, has implemented a house call program to follow up with high-risk patients released from acute care. The presenters will also discuss Call Us First!, an intervention to reduce unnecessary trips to the emergency department.

Nov. 2 Webinar

Building a Road Map for Patient Navigation: What to do when the mountains and oceans are constantly moving

Register today for this TMF Quality Innovation Network webinar covering transitions of care for patients within a complex health system on Thursday, Nov. 2, noon - 1 p.m. CT. Karen McIntosh, MSN, RN, CCM, Vice President of Transitions of Care, Washington Regional Medical Center, will present on the development of Washington Regional Medical Center's questions and assumptions that framed their road map for a patient navigator process. She will also address the logistics stemming from their population health management team's brainstorming sessions.

Nov. 7 Webinar

Implementing and Evaluating a Hospital-wide Performance Improvement Project to Reduce 30-day Psychiatric Readmissions

Register today for this webinar which takes place on Tuesday, Nov. 7, from noon - 1 p.m. CT. UTHealth Harris County Psychiatric Center (HCPC), an academic safety-net psychiatric hospital in Houston, Texas, will present how they implemented a hospital-wide performance improvement project to reduce 30-day psychiatric readmissions. Speakers Dr. Jane Hamilton and Stephen Glazier will describe evaluation metrics through the HCPC electronic health record and dashboards, as well as provide an overview of HCPC's two initiatives to reduce 30-day readmissions.

Nov. 8 Webinar

Engaging Physicians and Care Teams to Prevent and Manage Diabetes

Register today for the National Learning and Action Network Event on Nov. 8, 2 - 3:30 CT. Participants will learn about the American Medical Association’s (AMA) strategies and services for helping primary care and health systems implement prediabetes identification and referral processes for effective intervention. Participants will also learn the four critical times primary care should refer for diabetes self-management education and support (DSMES). Please reference the Joint Position Statement from the American Diabetes Association, the American Association of Diabetes Educators and the Academy of Nutrition and Dietetics for more information on DSMES including referrals, tools and assistance in implementing a standardized protocol.

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