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


C3_HHA_TMF MembershipMED.jpg
Data as of April 29, 2016.
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Data as of March 2016.
Click to view larger image.

Oct. 27 Campaign for Meds Management Webinar

Strategies for Diabetes Self-Management

This Campaign for Meds Management (CMM) event will identify strategies that patients/beneficiaries, families and caregivers can use to effectively manage diabetes and medication programs. A patient will highlight the challenges faced in diabetes management and the complexity of medication regiment, and will also share strategies for successfully managing diabetes in partnership with providers and other community resources. This webinar will be held on Thursday, Oct. 27, from 2 - 3 p.m. CT. Continuing education credit will be available. Learn more and register today.

Nov. 1 Webinar

Effective Co-Management of Mental & Physical Chronic Conditions

The Quality Improvement Organization (QIO) Program will hold a free virtual training session for health care providers to promote effective prevention and treatment of chronic disease. Speakers will also focus on the application of integrated care models. This training will take place Tuesday, Nov. 1, 2 - 3 p.m. CT. Register today.

Nov. 2 Open Forum

Readmissions/Medication Safety/Behavioral Health Open Forum

The TMF Quality Innovation Network Quality Improvement Organization (QIN-QIO) invites you to participate in the Readmissions, Medication Safety and Behavioral Health Open Forum. Quality improvement consultants will be available to answer questions and provide technical assistance. During this monthly Open Forum, your team can network with other providers and TMF QIN-QIO staff, ask questions and problem-solve relevant topics. This Open Forum will take place on Nov. 2, 2016, from noon - 1 p.m. CT. Register today.

Day of Event:
Please join 10 minutes prior to the presentation to ensure proper set up.

1. Go to the event page
2. Enter the Registration ID and event password: Forum
3. Click "Join Now."
4. Dial in to the teleconference: 888-884-2150. No access code required.

If you experience problems accessing the web portion of this meeting, please call the Ventech Solutions WebEx Helpline at 571-598-1988.

Submit Your Questions Now
If you would like to submit a question in advance of the Open Forum, you may email it to Your question will be answered during the call.

Nov. 8 Webinar

Understanding and Improving Your Home Health Agency's Star Ratings

This TMF Quality Innovation Network webinar will help you better understand your Star Rating. Medicare-certified Home Health Agencies participate in the Home Health Agency Star Rating Program, and ratings are based on quality performance data submitted by home health agencies in their Outcome and Assessment Information Set (OASIS) reports.This webinar will take place Tuesday, Nov. 8, from noon to 1 p.m. CT. Register today.

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