Action Items
Track implementation progress on readmission reduction initiatives from both your data analysis and current literature.
Overall Implementation Progress
3 of 32 action items completed
Critical Priority
0/6 completed
High Priority
3/17 completed
Medium Priority
0/9 completed
0-3 months
3-6 months
6-12 months
New action items from literature review — These items implement strategies from peer-reviewed studies demonstrating significant readmission reductions (2019-2025).
Assess telehealth platform capabilities
Evaluate current telehealth infrastructure for supporting post-discharge virtual visits
Pilot virtual transition clinic with hospitalist coverage
Launch pilot program with 2-3 hospitalists providing virtual follow-up within 7 days of discharge
Implement LACE+ risk stratification in EHR
Integrate LACE+ scoring to automatically identify high-risk patients for virtual clinic enrollment
Establish standardized PCP hand-off protocol
Create template for virtual clinic to communicate with primary care after each visit
Create After Hospital Care Plan (AHCP) template
Design personalized discharge booklet with medication schedule, appointment calendar, and warning signs
Implement PRAPARE screening on admission
Deploy validated SDOH screening tool to identify patients with social risk factors
Build community resource database
Create and maintain database of local resources for food, housing, transportation assistance
Launch pharmacist post-discharge medication review clinic
Establish pharmacist-led clinic for medication review within 7 days for high-risk patients
Create high-risk medication patient registry
Identify and track patients on anticoagulants, insulin, opioids for enhanced follow-up
Engage local PCP practices for 7-Day Pledge
Partner with 5-10 primary care practices to reserve same-week appointments for discharged patients
Implement appointment tracking system
Create system to verify patients attend scheduled 7-day follow-up appointments
Deploy 8P risk assessment tool
Implement 8P screening for all admitted patients to identify those needing enhanced discharge planning
Pilot RPM for heart failure patients
Deploy daily weight and BP monitoring for HF patients in first 7 days post-discharge
Establish RPM alert response protocols
Define thresholds and create protocols for nurse/provider response to abnormal values
Expand RPM to post-AKI and COPD patients
Deploy monitoring for additional high-risk populations based on pilot results
Evaluate AI readmission prediction tools
Assess available AI algorithms for predicting readmission risk and integration with EHR
Implement EHR-integrated decision support
Build standardized care pathways that trigger automatically based on diagnosis and risk factors
Partner with community organization for CHW support
Establish partnership to deploy community health workers for highest-risk patients
Implement CHW pre-discharge meeting protocol
Have CHWs meet with high-risk patients before discharge to establish rapport and identify needs
Audit current transitional care processes
Assess implementation of 20 evidence-based transitional care processes to identify gaps
Implement bedside rounds with patient participation
Include patients in discharge planning discussions during daily rounds
Establish population health management team
Create dedicated team for proactive outpatient management addressing medical and social domains
This is a demonstration of action item tracking. In a production environment, this would be connected to a database to persist changes across sessions.