title: To prevent readmissions, think outside the hospital walls.
abstract: Initiatives from the Centers for Medicare & Medicaid Services (CMS) and commercial payers that penalize hospitals when patients are readmitted make it necessary for providers throughout the continuum to collaborate and ensure that patients get the care they need. Create discharge plans that go beyond the hospital walls and coordinate with the post-acute providers to ensure that they have the information they need to help the patient follow the plan. Develop close relationships with post-acute providers by meeting with them face to face and discussing ways to improve transitions and solve problems. Track quality metrics, such as readmission rates, and share them with the providers. When patterns occur, alert the group to work on solutions.
mesh_terms: D019090:Case Management; D003266:Continuity of Patient Care; D003299:Cooperative Behavior; D006801:Humans; D010351:Patient Discharge; D010359:Patient Readmission; D011785:Quality Assurance, Health Care