How Reducing Hospital
Readmissions
Applies to You
Everybody plays a part in reducing hospital readmissions. There is something we can all do to have an impact. But how?
Below is a table outlining a sample of interventions selected due to their high probability of impact that suggests how
each type of participant might engage in these interventions. These interventions have been identified by local and
national experts as those that address key issues impacting hospital readmissions while reducing overall costs.
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Teachback – a strategic transfer of information from caregiver to patient
Improving care transitions and communication across the continuum of care while engaging partners and
providers of all types
Increased focus on end of life issues (advanced directives, social service needs, patient and provider education)
Providers
Develop a Teachback competency
program
Incorporate Teachback into existing
processes & systems of care for certain
patients or disease types
Seek feedback from patients to learn
more about what is needed in your
Teachback program.
Payers
Purchasers/Employers
Teachback
Public/Patients
Raise awareness of Teachback
Raise awareness of Teachback
Raise awareness of Teachback
Provide health literacy education
Provide health literacy education
Provide health literacy education
Provide reimbursement for
Teachback activities
Raise expectation of Teachback
for certain patients or disease
types with employees
Teach importance of adherence
to care plan and follow up with
PCP
Potential Benefits
o More informed, active, and compliant
patients
o Reduce preventable readmissions
Healthier patients; lower costs
Decreased time off from work due
to illness or caring for elderly
parents or family members
More active in their own
healthcare; overall are happier
and healthier
End-of-Life (EOL)
Incorporate EOL discussions into
existing processes & systems
Provide education of benefits to
providers and patients
Provide education & resources for
employees on advance directives
& EOL benefits
EOL education of benefits and
advance directives
Inquire about Advanced Directives &
counsel on their importance
Evaluate reimbursement status
for EOL counseling
Develop employee incentives
related to advance directives
Identify community resources
for EOL (counseling, hospices
etc.)
Potential Benefits
o Increased patient satisfaction
o More informed and prepared patients
o Increased patient satisfaction
o More informed and prepared
Increased employee satisfaction
patients
More equipped to cope with the
unexpected & difficult decision
making
Care Transitions
Partner with providers in different
settings, payers, etc.
Partner with providers &
purchasers
Partner with providers and payers
Partner with payers and
providers
Redesign discharge process and handoff
processes
Set expectations of what needs
to be achieved during transitions
Provide tips to employees on how
to navigate the healthcare system
& become active in their health
Raise awareness and
expectations in community
o Fewer adverse events
o Improved flow of information from
Potential Benefits
o Streamlined processes and
o Lower costs
o More active in own
systems between provider
healthcare, overall healthier &
o Increased employee satisfaction
other provider settings patients
o Lower costs
o Increased patient satisfaction & health
o Better management of care
o Increased patient and
types
consumer satisfaction &
health
o Lower costs
& health
happier, improved flow of
information from other
provider settings patients
o Lower costs
o Fewer adverse events
o Comfort in knowing “who’s
in charge”
This material was prepared by HealthInsight under a contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (DHHS). The contents presented do not
Necessarily reflect CMS policy. PUB # 10SOW-NV-2011-CT-2
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