Recommendations
Evidence-based recommendations combining your survey data analysis with current literature on readmission reduction strategies.
3
Critical Priority
Highest Impact
9
High Priority
Strong Evidence
4
Medium Priority
Supporting Strategies
Already Implemented
HF & Catheter Bundles
New strategies from current literature (2019-2025) — These recommendations are based on peer-reviewed studies and institutional case reports demonstrating significant readmission reductions. They complement your existing heart failure and catheter bundles.
Virtual Transition of Care Clinic
Telemedicine-based transition clinic for high-risk patients seen within one week of discharge. UC San Diego Health demonstrated 14.9% vs 20.1% readmission rates.
Expected Impact: 5.2% absolute reduction in 30-day readmissions
Predictive AI and EHR Automation
EHR-integrated decision support with predictive AI to identify highest-risk patients and standardize inpatient care at the point of care.
Expected Impact: 4% absolute reduction, eliminated equity gaps
Remote Patient Monitoring (RPM)
Home-based digital monitoring for high-risk patients with structured alert protocols and provider response systems.
Expected Impact: 59% reduction in hospitalizations within 6 months
Project RED (Re-Engineered Discharge)
AHRQ-funded comprehensive discharge program with 12 standardized components and After Hospital Care Plan (AHCP).
Expected Impact: 30% fewer readmissions and ED visits
Project BOOST (8P Risk Assessment)
Society of Hospital Medicine initiative using 8P risk assessment tool to identify high-risk patients for enhanced discharge planning.
Expected Impact: 2% absolute reduction (14.7% to 12.7%)
7-Day Pledge Program
Community-wide infrastructure connecting patients to primary care within 7 days of discharge through partnerships with local practices.
Expected Impact: 4.8% absolute reduction in 30-day readmissions
Community Health Worker Program
Community health workers provide bridge between hospital and home through phone calls, text messages, home visits, and social resource connection.
Expected Impact: 56% reduction in odds of readmission
Pharmacist-Led Medication Therapy Management
Hospital-based pharmacist-led post-discharge medication review addressing adherence barriers, interactions, and regimen simplification.
Expected Impact: 22% reduction in 30-day readmissions
Social Determinants of Health Screening
Systematic screening for social risk factors (food, housing, transportation) with connection to community resources before discharge.
Expected Impact: Variable - addresses root causes
Comprehensive Transitional Care Process
Systematic implementation of evidence-based transitional care processes across pre-discharge, at-discharge, and post-discharge domains.
Expected Impact: 0.185% reduction per additional process implemented