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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


Sept. 12 - Nov. 7 Conference

Register today to attend the Oklahoma Health Care Quality Improvement Conference, hosted by TMF Health Quality Institute, the Medicare Quality Innovation Network Quality Improvement Organization (QIN-QIO) in Oklahoma. The TMF QIN-QIO is hosting four free, in-person conference events throughout Oklahoma between September and November 2018. Health care professionals, community partners and others interested in health care quality improvement in Oklahoma are invited. Attendees will have the opportunity to earn free continuing education credits.

Aug. 28 Webinar

Medication Safety Affinity Group

Register today for this TMF Quality Innovation Network region-wide Medication Safety Affinity Group on Tuesday, Aug. 28, 2018, 2 - 3 p.m. CT. Providers in Arkansas, Missouri, Oklahoma, Puerto Rico and Texas are invited to join us for an open discussion around potentially inappropriate medications in older adults. Bring your ideas and barriers to our discussion.

Aug. 28 Webinar

Home Health QRP Webinar Part 1—Introduction to the OASIS-D

Register today for this webinar on Tuesday, Aug. 28, 2018, from 1 to 3 p.m. CT. This presentation will deliver a high-level overview of the major changes being made to the OASIS-D related to the Home Health Quality Reporting Program (QRP) on Jan. 1, 2019, as well as introduce resources that are available to implement the OASIS-D.

Sept. 5 Webinar

Home Health QRP Webinar Part 2—Section GG: Functional Abilities and Goals

Register today for this webinar on Wednesday, Sept. 5, 2018, from 1 to 3 p.m. CT. This presentation will give an in-depth overview of the new quality measure and data item changes being made related to Section GG of the OASIS-D that will take effect on Jan. 1, 2019. Specific topics include new assessment items, practice coding scenarios and instructions and resources to facilitate use of the OASIS-D.

Sept. 6 Webinar

Person-Centered Approaches to Support People Dually Eligible for Medicare and Medicaid

Register today for this free webinar on Thursday, Sept. 6, 2018, from 1 to 2:30 p.m. CT. This presentation will go over information on person-centered practices, the benefits of these approaches and the settings and opportunities in which to apply person-centered care.

Sept. 12 Webinar

Disparities LAN Event

Register today for this Learning and Action Network (LAN) webinar on Wednesday, Sept. 12, 2018, from 2 to 3:30 p.m. The topic of this call is Addressing Disparities in Long-Term Services and Supports: Strategies for Culturally and Structurally Competent Services. Attendees will learn information about disparities in long-term services, how cultural competency and structural competency can relate to disparity rates and more. Continuing education credits may be available.

Oct. 11 Webinar

The Role of Data in the Opioid Crisis

Register today to attend this webinar on Thursday, Oct. 11, from 10 a.m. to noon, hosted by the Centers for Medicare & Medicaid Services. Webinar attendees will explore existing data resources to help understand opioid prescription practices and drive improvements, identify best-practice methods for using data to decrease inappropriate opioid prescriptions and have the opportunity to collaborate and network with clinicians and leaders across the care continuum to reduce opioid misuse.

Texas • Arkansas • Missouri • Oklahoma • Puerto Rico