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
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.