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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.

Home Health Agency Banner to Maximize Their Membership 

Quick Links

Download these resources to learn more about the Readmissions Network.

Fact Sheet and Infographics

Network Videos

Community Charters

Data Portal


TMF QIN Oklahoma 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 October 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.

Oct. 18 Webinar

The Person & Family Engagement Initiative: BFCC-QIO Services for Medicare Beneficiaries

Register today for the TMF Quality Innovation Network webinar on The Person & Family Engagement Initiative on Thursday, Oct. 18, 2018, noon - 1 p.m. CT. Participants will learn more about the Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO), KEPRO. KEPRO offers four free services to Medicare beneficiaries and their families: beneficiary complaints, discharge appeals, Immediate Advocacy and Patient Navigation. This webinar will focus on Patient Navigation, a program that helps Medicare patients navigate the heath care system and better understand the care they receive.

Oct. 23 Webinar

Medication Safety Affinity Group: Understanding Addiction and Discovering the Power of Goals

Register today for this TMF Quality Innovation Network region-wide Medication Safety Affinity Group on Tuesday, Oct. 23, 2018, 2 - 3 p.m. CT. Providers in Arkansas, Missouri, Oklahoma, Puerto Rico and Texas are invited to join us for a presentation and open discussion around addiction. Bring your ideas and barriers to our discussion.

Oct. 23 Webinar

Special Considerations with Medication Management of Cardiovascular Disease in Older Adults

Register now for this webinar on Tuesday, Oct. 23, from noon to 1 p.m. CT. The TMF Quality Innovation Network's Hennie Garza, MSPharm, RPh, project director for pharmacy, will speak on this webinar. Using recommendations from current guidelines and medical literature, she will discuss safety considerations when using common medications to manage cardiovascular disease in older adults. This webinar is co-sponsored by Alliant Quality, atom Alliance, AQIN, HQI, Telligen and the TMF QIN – Medicare Quality Innovation Network Quality Improvement Organizations (QIN-QIOs).

Oct. 31 Webinar

Remote Patient Monitoring Technologies to Improve Quality Outcomes - Reducing Readmissions

Register today for a discussion highlighting remote patient monitoring technology strategies and outcomes on Wednesday, Oct. 31, 11 a.m. - noon CT. Evidence from literature, as well as information from technology companies and services, will be reviewed to raise awareness of emerging strategies to improve quality of care and patient outcomes utilizing technology. Attendees will have the opportunity to free continuing education credits.

Nov. 15 Webinar

The Senior Counseling Center: A Model for Addressing Mental Health in Aging Adults

Register today for a TMF Quality Innovation Network webinar on the Senior Counseling Center on Thursday, Nov. 15, 2018, noon - 1 p.m. CT. The Senior Counseling Center is a premier intensive outpatient program that seeks to remove as many barriers to mental health care as possible for aging adults. The program provides wrap-around services for seniors with mental health problems. The discussion will center around the treatment/program model, screening and assessment tools and the amazing results we see when seniors are provided the needed resources for mental health progress.

Texas • Arkansas • Missouri • Oklahoma • Puerto Rico