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61. Primarycareeffortstoreducereadmissions-Envscan (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/PrimaryCareEffortsToReduceReadmissions-envscan.pdf
    March 01, 2020 - • Patients identified as high risk for readmission. … • Study design: pre-post analysis of readmission rates. … But 180-day readmission rates were similar between the two groups. … Medicare readmission rates showed meaningful decline in 2012. … /article/420566/ 44 reduces-ed- readmission/article/420566/.

62. Tool 6: Portfolio Presentation (ppt file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/mcaidread_tool6_op_dashboard.ppt
    June 02, 2025 - Outcomes: Track readmission rates for the hospital and for the target populations monthly to visualize … consisting of measures of monthly discharge volume; monthly implementation measures; and monthly outcomes (readmission … Staff: Readmission champion and day-to-day leader. … May May May June June June June All Discharges Total Target Population Target Pop 1 Target Pop 2 Readmission

63. CHIPRA 207: Section 2, Tables 1-5 (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-207-section-2-tables-1-5.pdf
    June 02, 2025 - Readmission within 7 days Mean Std Dev Min Max IQR Deciles 10% 20% 30% 40% 50% 60% 70% 80% 90% … Readmission within 14 days Mean Std Dev Min Max IQR Deciles 10% 20% 30% 40% 50% 60% 70% 80% 90% … Readmission within 30 days Mean Std Dev Min Max IQR Deciles 10% 20% 30% 40% 50% 60% 70% 80% 90% … Readmission Rates Stratified by Federal Insurance Readmission 7 Days Readmission 14 Days Readmission … 30 Days Readmission 90 Days Readmission 365 Days Rate (CL) N Rate (CL) N Rate (CL) N

64. Tool 9: Transitional Care Planning (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/mcaidread_tool9_trans_care.docx
    July 28, 2016 - Description This tool provides discharge planners with a set of prompts to identify readmission risks … Staff Day-to-day readmission reduction champion to test, adapt, and incorporate into existing workflow … The message from this person-centered view of readmissions is that no single issue defines readmission … “whole-person” view of transitional care and ongoing care needs to better identify not only risk of readmission … Interdisciplinary Care Planning and Coordination · Obtain high-risk readmission team consult · Contact

65. Tool 4: Community Inventory (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/mcaidread_tool4_comm_inv.docx
    June 02, 2025 - Staff Readmission reduction champion as a component of strategic planning; delegated to day-to-day lead … Your readmission reduction team can probably identify a handful of the below-listed providers or agencies … ] · · Skilled nursing facilities [onsite providers, warm handoffs, joint readmission reviews, … ] · · Home health agencies [warm handoffs, joint readmission reviews, front-loaded home visits … ] · · Hospice [warm handoffs, joint readmission reviews, same-day home visits, etc.

66. Tool 8: Conditions of Participation Handout (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/mcaidread_tool8_cop_handout.docx
    November 01, 2015 - It can be used as a handout, in educational sessions, and as a guide to the work of your readmission … Staff Readmission reduction champion (in strategic planning); day-to-day leader (education and improvement … Time Required 10 minutes to review and consider circulating or discussing at next readmission team meeting … discharge planning for all inpatients, observation patients, and certain ED patients; Analyze and track readmission … For more information, contact [Readmission Champion]. 2 image1.png image2.jpeg

67. Neonatal Intensive Care All-Condition Readmissions Without Gestational Age, Section 7d: Supplementary Tables (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-208-section7d.pdf
    June 02, 2025 - Readmission Rates Stratified by State and by Rurality/Urbanicity Table 17. … Readmission Rates Stratified by Rurality/Urbanicity Readmission 7 Day Rate (CL) Readmission 14 Day … Rate (CL) Readmission 30 Day Rate (CL) Readmission 90 Day Rate (CL) Readmission 365 Day Rate

68. Neonatal Intensive Care All-Condition Readmissions Without Gestational Age, Section 7a: Supplementary Tables (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-208-section7a.pdf
    June 02, 2025 - SUPPLEMENTARY TABLES Table 12: Readmission Rates Stratified by State and by Race/Ethnicity Table … Readmission Rates Stratified by Race/Ethnicity Readmission 7 Day Rate (CL) Readmission 14 Day Rate … (CL) Readmission 30 Day Rate (CL) Readmission 90 Day Rate (CL) Readmission 365 Day Rate (CL

69. Penn Medicine Chester County Hospital Implements AHRQ Toolkit to Reduce Readmissions | Agency for Healthcare Research and Quality
    www.ahrq.gov/news/newsroom/case-studies/201506.html
    April 01, 2015 - This enables patients to manage their conditions at home, possibly avoiding a readmission to the hospital … Without adding additional nursing resources, we achieved a 50 percent reduction in the readmission of … Since RED's hospital-wide implementation, the average readmission rate for congestive heart failure is … The readmission rate for chronic obstructive pulmonary disease also dropped, from 19 to 11.7 percent. … admission, teach-back, making follow-up appointments, follow-up phone calls for patients at high-risk for readmission

70. Neonatal Intensive Care All-Condition Readmissions Without Gestational Age, Section 7c: Supplementary Tables (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-208-section7c.pdf
    June 02, 2025 - Readmission Rates Stratified by State and by Percent Below Federal Poverty Line, by Quartile Readmission … 7 Day Rate (CL) Readmission 14 Day Rate (CL) Readmission 30 Day Rate (CL) Readmission 90 Day … Readmission Rates Stratified by State and by Percent with High School Diploma, by Quartile Readmission … 7 Day Rate (CL) Readmission 14 Day Rate (CL) Readmission 30 Day Rate (CL) Readmission 90 Day … ) Readmission 14 Day Rate (CL) Readmission 30 Day Rate (CL) Readmission 90 Day Rate (CL) Readmission

71. Primary-Care-Based-Efforts (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/primary-care-based-efforts.pdf
    March 01, 2019 - • Patients identified as high risk for readmission. … • Study design: pre-post analysis of readmission rates. … But 180-day readmission rates were similar between the two groups. … Medicare readmission rates showed meaningful decline in 2012. … /article/420566/ 44 reduces-ed- readmission/article/420566/.

72. 0129Table9 (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/0129table9.pdf
    January 01, 2008 - Table 9 – Analysis of Disparities in Readmission Risk Based on Race/Ethnicity 2005-2009 AHRQ Revisit … Hispanic 1.24 [1.20 – 1.29] Other 1.03 [0.98 – 1.07] Table 10 – Analysis of Disparities in Readmission … 1.07 [0.91 - 1.26] Native American 1.09 [0.99 - 1.20] Table 11 – Analysis of Disparities in Readmission

73. Section 7-A, Tables 10, 11, and 12 (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-131-section-7-a-table-10-11-12.pdf
    January 01, 2008 - Table 10 – Analysis of Disparities in Readmission … 1.38] Hispanic 1.33 [1.20 – 1.48] Other 1.08 [0.95 – 1.22] Table 11 – Analysis of Disparities in Readmission … Mixed 1.48 [1.06 - 2.07] Native American 1.26 [1.06 - 1.50] Table 12 – Analysis of Disparities in Readmission

74. Seamless Care: Safe Patient Transitions from Hospital to Home (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Spehar.pdf
    April 18, 2004 - We identified patient characteristics that were associated with a high risk of unscheduled readmission … DRG category 109 (CABG) had the lowest overall 30-day readmission rate, and the readmission rate was … secondary diagnosis, the likelihood of a readmission increased 1.2 times. … Age, gender, and race were not predictive of readmission in any of the models. … ICU readmission after cardiac surgery. Eur J Cardio-thoracic Surg 2003;23(3):354–9. 51.

75. Designing & Delivering Whole-Person Transitional Care The Hospital Guide to Reducing Medicaid Readmissions Webinar 6
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/aspire_webinar6/aspire_webinar6.pptx
    June 02, 2025 - How to Use This Guide Analyze Your Data Survey Your Current Readmission Reduction Efforts Plan a Multi-Faceted … With Cross-Continuum Providers Enhance Services for High-Risk Patients List of Tools Data Analysis Readmission … provided to all patients as part of routine care; Offered to subgroups identified as “high risk” of readmission … other entities High Risk Target Populations There may be several target populations at high risk of readmission … Transitional Care Plan Identifies post-hospital needs, patient priorities, and readmission risks and

76. Final Progress Report: Benchmarking Patient Safety and Quality in U.S. Hospitals: The Stochastic Frontier Approach (pdf file)
    www.ahrq.gov/sites/default/files/2025-02/unruh-report.pdf
    January 01, 2025 - Gap between actual and best possible score on heart failure 30- day readmission rate SFA Gap in … pneumonia readmission Gap between actual and best possible score on pneumonia 30- day readmission … The 30-day mortality and readmission measures came from the CMS' Acute Myocardial Infarction Heart … Heart failure readmission 24.59 2.20 22.78 0.94 1.77 1.47 8 6 Pneumonia readmission 18.29 1.78 16.52 … and higher gaps for six regions for pneumonia readmission.

77. Webinar 6: Enhance Services for High-Risk Patients | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/resource/guide/web6.html
    December 01, 2017 - Survey Your Current Readmission Reduction Efforts. … Readmission Review. Hospital Inventory. Community Inventory. Portfolio Design. … S urvey Your Current Readmission Reduction Efforts. … Offered to subgroups identified as "high risk" of readmission. … Slide 31: Summary Deploy enhanced services for patients at high risk of readmission.

78. Webinar 5: Reach Out to Collaborate with Partners Across Settings: Slide Presentation | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/resource/guide/web5.html
    December 01, 2017 - Survey Your Current Readmission Reduction Efforts. … Readmission Review. Hospital Inventory. Community Inventory. Portfolio Design. … S urvey Your Current Readmission Reduction Efforts. … Start with common agenda items: Readmission data. Readmitted patient stories. … Readmission stories from "receiver" perspective. Handoff communication.

79. Resources and Tools To Improve Discharge and Transitions of Care and Reduce Readmissions | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/about/areas/improve-discharge.html
    August 01, 2024 - (journal article) Implementation of the Re-Engineered Discharge (RED) Toolkit To Decrease All-Cause Readmission … Project Re-Engineered Discharge (RED): The Impact of a Pharmacist Telephone Intervention on Hospital Readmission … Rates (journal article) RED Toolkit Impact Case Studies: Pennsylvania Psychiatric Institute Slashes Readmission … Briefs - Readmissions and Revisits PSNet Materials: AHRQ PSNet article: Association of Changing Hospital Readmission

80. Tool 12: Cross Continuum Collaboration Tool (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/mcaidread_tool12_collaboration.docx
    June 02, 2025 - Description Hospital readmission reduction teams need to identify the clinical, behavioral, and social … Staff Readmission day-to-day champion. Time required 2 hours to review and apply recommendations. … Make a request - getting started: You have a process in place to identify patients at high risk of readmission … the social/behavioral or other transitional care needs among patients identified as at high risk of readmission