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TMF QIN

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

Resources

Jan. 17 Webinar

January Medication Safety Affinity Group

Register today for TMF Quality Innovation Network's monthly Medication Safety Affinity Group on Jan. 17, 2018, 3:30 - 4:30 p.m. CT. Providers throughout the region are invited to participate in this call to improve care for Medicare patients by learning about medication reconciliation among providers; reducing adverse drug events and polypharmacy; reducing unnecessary hospital admissions and readmissions; improving medication adherence; and best practices, lessons learned and evidence-based guidelines from other providers in the region. Note: This event was previously titled "Clinical Pharmacist-led Call."

Jan. 18 Webinar

Utilizing Data to Support Readmissions Reduction Efforts

Register today for this TMF Quality Innovation Network presentation on Jan. 18, 2018, noon - 1 p.m. CT, to learn about using data to support readmissions reduction efforts. Participants will learn how they can use data reports to aid in their decision-making process of intervention selection and implementation. Speakers will review the Centers for Medicare & Medicaid Services initiatives and how they relate to readmission reduction efforts.

Jan. 18 Webinar

HHQI Quarterly Underserved Population Webinar

Register today for this educational webinar presented by the Home Health Quality Improvement (HHQI) National Campaign will discuss heath literacy barriers and strategies for various areas including: measurement, navigation, verbal/written communication, and evaluation. Presenters are HHQI Project Coordinators Misty Kevech, RN, MS and Cindy Sun, RN, MSN. This activity has been approved for 1.5 hours of continuing education (CE) credit by the Alabama State Nurses Association, an accredited approver of nursing continuing education through the American Nurses Credentialing Center’s Commission on Accreditation (ANCC).

Feb. 27 Webinar

HHQI Heart Month Webinar

Register today for this Heart Month webinar focusing on a cardiac rehab roundtable on Tuesday, Feb. 27, 2018, 1 - 2:30 p.m. CT. Evidence suggests hospital readmission and all-cause mortality rates are reduced when patients who have experienced a heart attack participate in cardiac rehab. This is often a missed opportunity. Learn which diagnoses are included, what services beyond supervised exercise are incorporated, and what options are available for those who are unable to attend an outpatient program.


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