This Expert Panel is Archived.

This Expert Panel is no longer active as of December 2018. Thanks to those who posted here and made this information available to others visiting the site.

Reducing Readmissions, Improving Transitions in Care

Posted: 13 Oct, 2014   Recommendations: 2   Replies: 12

The Affordable Care Act has placed significant emphasis on reducing hospital readmission rates, and hospitals around the country now face financial penalties through Medicare’s Hospital Readmissions Reduction Program (HRRP) if patients with certain conditions are readmitted within 30 days of discharge. Ensuring that patients, as well as their caregivers and health care providers, are prepared for the transition from the hospital to home is an area ripe for improvement. This transition time is often a weak link, exposing the highly fractured nature of health care delivery systems in the United States.

To discuss these important issues, and highlight strategies for improving transitions in care, we invite you to join us next week, October 20th – 24th, for a unique GHDonline video Expert Panel.

During this video Expert Panel, GHD Faculty Director Rebecca Weintraub will interview Jeffrey Schnipper, MD, MPH, FHM, who currently serves as the Director of Clinical Research at Brigham and Women’s Hospital. Dr. Schnipper is also an Academic Hospitalist Service Associate Physician in the Division of General Medicine at BWH and an Assistant Professor of Medicine at Harvard Medical School.

During this video interview, Dr. Schnipper will discuss his current research and address the following questions:

     1. Why are transitions in care such a persistently difficult problem for delivery systems around the country?

      2. What are the components for improving transitions in care? How have you identified which elements represent the greatest opportunity for improvement?

      3. How can health care providers manage the tension between seemingly competing goals of reducing readmissions while also decreasing a patient’s length of stay in the hospital?

      4. What role do patients and caregivers play in improving transitions in care? How have you worked with patients and caregivers as you conduct your research?

This panel is part of our US Communities Initiative, which is supported by the Agency for Healthcare Research and Quality (AHRQ), and aims to foster discussions between health care professionals on evidence-based practices, and translating these practices across disparate settings, to improve health care delivery in underserved populations in the US.

In an effort to understand the impact of our Expert Panels, we’ve created a short (4 question) survey. Your responses are greatly appreciated—please take the survey survey before the discussion begins:

We look forward to a rich discussion next week – please join the conversation and share your questions or comments!



Mwawi Nyirongo Replied at 8:13 AM, 16 Oct 2014

Dear Marie,
Thanks for inviting me in this discussion which is of great importance. I
will respond to the survery as soon as possible.

Rebecca Jurbala Replied at 10:25 AM, 16 Oct 2014

A reminder that our very short Expert Panel survey is open until Monday morning - your responses to these 4 questions will help us evaluate the impact of these types of discussions here at GHDonline and provide us with incredibly helpful feedback. Please take a moment to fill out the survey if you haven't already:

Thank you!

Bienvenu MUVUNYI Replied at 2:42 PM, 16 Oct 2014

So grateful for inviting me to this wisdom panel.


Gaddo Flego Replied at 4:25 PM, 16 Oct 2014

Thank you for inviting me to this very meaningful panel.

Dan Jackson TWIZELIMANA Replied at 4:35 PM, 16 Oct 2014

This is a wonderful event!Thank you for the invitation

A/Prof. Terry HANNAN Replied at 4:57 PM, 16 Oct 2014

The citation below from this week's NEJM shows that unless clinical decision making issues are addressed in health care delivery e.g. by legislation, there is no significant improvement in health care delivery or resource utilisation. There is some evidence it makes care delivery worse. Terry Hannan
The Effect of Malpractice Reform on Emergency Department Care.
Daniel A. Waxman, M.D., Ph.D., Michael D. Greenberg, J.D., Ph.D., M. Susan Ridgely, J.D., Arthur L. Kellermann, M.D., M.P.H., and Paul Heaton, Ph.D.
N Engl J Med 2014; 371:1518-1525October 16, 2014DOI: 10.1056/NEJMsa1313308

Marie Connelly Replied at 10:51 AM, 20 Oct 2014

Many thanks to everyone for joining us in this unique, video Expert Panel! Our video interview with Dr. Jeffrey Schnipper is now available on GHDonline. We encourage you to share thoughts and questions for Dr. Schnipper throughout the week, as well as other examples of programs working to improve transitions in care that you are familiar with from your own work.

(For those following along over email, you can watch the video by visiting this discussion on the web:

As we kick off the discussion today, I'm curious to hear whether others have thoughts on the question of why transitions in care is such a difficult problem to solve here in the US. I hope our colleagues working in other countries will also share ideas and examples we might learn from as well.

Vincent NDAYIRAGIJE Replied at 2:09 PM, 20 Oct 2014

Thanks for the invitation!

GP - MOH - Muhima Hospital
Design Officer-MEDFOSTER(
Reasearch Assistant-Mobile Doctor Educator
Head-Training Committee-Healthy People Rwanda(www.*hprwanda*.org)

Sudip Bhandari Replied at 12:55 PM, 23 Oct 2014

I’d like to highlight some important resources around reducing readmissions.

The first attached resource, “Medicare Hospital Readmissions Reduction Program” provides a great overview on the issue of readmission, current debates and research, programs introduced to reduce readmissions, and what needs to be done next. The article highlights an approach called Project RED (Re-Engineered Discharge) that has shown to be successful in reducing readmissions. Project RED, with its two very simple strategies (nurse-discharge advocate assigned to follow a patient throughout the discharge process, and production of after-hospital care plan) reduced hospital readmission rate by 30 percent in a month.

The second resource I’ve attached is a comprehensive hospital guide developed by Agency for Healthcare Research and Quality (AHRQ) to reduce Medicaid readmissions. The guide details some of the best evidence-based strategies to reduce readmissions.

The third article attached here delves into the role Patient Safety Organizations (PSOs) in reducing care. PSOs are institutions that aim to improve care by reducing preventable medical errors.

I am curious to hear thoughts from members here about these documents—do you have experiences with efforts like the Project RED program? How are your organizations currently working to reduce readmissions?

To Jeff, I wonder if you could speak more to your program’s efforts to engage the community (local organizations, patient groups, etc) in reducing readmissions? Are there approaches here you think have significant potential?

Attached resources:

Marie Connelly Replied at 1:52 PM, 23 Oct 2014

Many thanks for sharing these resources, Sudip! I look forward to hearing from our colleagues in the community about their experience with Project RED and similar efforts to reduce readmissions and improve transitions in care.

I'm also interested to hear more about how an integrated, team-based approach to care can support efforts to reduce readmissions—particularly around the pillar/support that Jeff describes of patient engagement. How can hospitals lay the groundwork at discharge to support patients and families being strongly invested and engaged in their care, and how can this be transitioned to the community after discharge.

Looking forward to hearing your thoughts! And as a reminder, we encourage you to share your own questions for Dr. Schnipper—we'll be sharing his responses later this week.

Marie Connelly Replied at 1:37 PM, 27 Oct 2014

While I hope we'll have additional thoughts and feedback to share from Jeff shortly, I wanted to take a moment to thank everyone for joining us for this unique video Expert Panel—we would be grateful for your feedback in our short follow up survey. These surveys help us understand the impact of our Expert Panel discussions, and your feedback is incredibly valuable to us.

Please take the survey now, by visiting:

Sudip Bhandari Replied at 9:10 AM, 12 Jan 2015

Many thanks again to our panelist and members who participated in this Expert Panel discussion in October 2014!

To help us understand the longer-term impact of these Expert Panels and plan future events, we have created a very short, 5 question, follow-up survey. This survey will only take 2-3 minutes of your time—please take the survey now at:

Many thanks,

This Expert Panel is Archived.

This Expert Panel is no longer active as of December 2018. Thanks to those who posted here and made this information available to others visiting the site.