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Readmissions Summary:


What Are They?

"Readmission" occurs when patients who have had a recent stay in the hospital go back into a hospital again. Patients may have been readmitted back to the same hospital or to a different hospital or acute care facility. They may have been readmitted for the same condition as their recent hospital stay, or for a different reason. Often referred to as "rehospitalization."

Who's At Risk?

Patients in transition - those moving from one care setting to another - are at increased risk for hospital readmission.  Unanswered questions including  the following, can increase patient risk for readmission: who is in charge of the patient transition, what is the plan, whether the plan and follow-up instructions are understood, and knowledge of whom to call with questions once they are home or in their new care setting.

What's At Stake?

Patients move from one setting of care to another or to one set of care providers to another during an episode of illness. As patients and families navigate across new care settings and among different care providers, they often encounter communication challenges and confusion around who is clearly accountable for their care. This can lead to medical errors, duplication, increased costs and may also lead to higher rates of hospitalization.

What Providers Are Doing to Prevent Readmissions?

Massachusetts is currently participating in many projects to address and improve hospital readmission issues.  These efforts are largely coordinated state-wide by the Massachusetts Care Transitions Forum, and a list of these projects follows.

  • Re-Engineered Discharge (RED) Toolkit from AHRQ
  • Potentially Preventable Readmissions (PPR) Project with 3-M
  • STAAR Initiative:  STate Action on Avoidable Rehospitalizations
  • Interventions to Reduce Acute Care Transfers (INTERACT-II) Initiative
  • MOLST Demonstration Project:  Medical Orders for Life-Sustaining Treatment
  • Project RED (Re-Engineered Discharge)
  • Project BOOST (Better Outcomes for Older Adults through Safe Transitions)
  • Home Care Projects:  Masspro Collaborative Project
  • Business-led Projects:  Dovetail Health's Pharmacist-Led Transition Services to Avoid Costly Readmissions



Reducing Readmissions in Massachusetts: A New Report

In a state-of-the-state MHA report, we look at generally accepted readmissions data, identify opportunities for improvement, and detail readmission reduction best practices now underway at Massachusetts hospitals.

Read full report...  


On May 18, 2016 Pat Noga, PhD, RN, MBA, NEA-BC of Clinical Affairs at MHA conducted a webinar presentation and discussion on the new State of the State: Reducing Readmission in Massachusetts report.


Pat, along with Steven M. Defossez, MD, EMHL, V.P., Clinical Integration at MHA and Amy E. Boutwell, MD MPP, President, Collaborative Healthcare Strategies shared the key findings of the paper, which uses data to point out specific paths for improvement, and details some of the best readmission reduction practices now underway in the state. 

During the webinar,   Pat also discussed with the participants the types of readmission reduction strategies that their organizations have put into place and what has made a difference in reducing readmissions.

Click here for to access a recording of the May 18th webinar.


3M Heath Information Services Potentially Preventable Readmission (PPR) Reports Webinar

In 2013, MHA's Board of Trustees challenged acute care hospitals to reduce readmission rates by 20 percent over the next three years.  To track progress toward that goal, MHA contracted with 3M PPR Classification System. 3M recently provided MHA with a statewide acute care hospital 30-day risk-adjusted PPR rate and analysis for FY 2012 to use as the baseline readmission measure. The analysis employed the Massachusetts acute care hospital discharge database obtained from the Center for Health Information and Analysis.

The contract with 3M also called for the production of hospital-specific PPR data reports to inform each hospital about their readmission profile and provide insights that may assist them with their readmission reduction efforts. Those reports were distributed by e-mail to acute care hospital CEOs on May 30 2014, A recording of the July 8, 2014 webinar explaining the PPR methodology and review the content of the hospital-specific reports can be found here.



     Hospital Guide to Reducing 

        Medicaid Readmissions

A guide to help acute care facilities expand their current Medicaid readmission efforts is now available from AHRQ.
The new resource, titled Hospital Guide to Reducing Medicaid Readmissions, can help acute care facilities accomplish the following:


  • Adapt or expand existing Medicaid readmission reduction efforts. It helps identify readmission risks, transitional care needs, and adapt best practices from proven strategies like AHRQ's Re-Engineered Discharge, the Institute for Healthcare Improvement's State Action on Avoidable Readmissions, and the Society of Hospital Medicine's Better Outcomes for Older Adults Safe Transitions to serve the transitional care requirements of Medicaid patients.
  • Develop your Medicaid reduction strategy using the guide's roadmap featuring 13 customizable online tools. The tools can be downloaded individually here.
    Comply with CMS' Conditions of Participation requirements for a standard, improved, and transitional care for all patients. National, state, and local data show high rates of non-obstetric Medicaid readmissions.
  • Develop partnerships across other settings of the healthcare continuum. The tool helps create an inventory of resources and processes to aid building multidisciplinary teams with organizations and facilities offering post-hospital Medicaid transitional services. 

The guide is the only federal tool available tailored for the adult Medicaid population. Hospitals at different stages of readmission reduction work can benefit from implementing this guide. 


Six Strategies Hospitals Can Use to Reduce Their Readmission Rates

While there have been dozens of campaigns launched to help hospitals reduce their patient readmission rates, not much evidence exists to show which strategies are most effective.

In a study in Circulation: Cardiovascular Quality and Outcomes (July 2013 6(4):444-50) click here focused on heart failure patients, Yale University researcher Elizabeth Bradley and colleagues sought to find out which methods seem to have the greatest association with significantly lower 30-day readmission rates. The investigation, which drew from a survey of hospitals participating in national quality campaigns, yielded six effective strategies-only a few of which have been implemented by more than a third of the hospitals.

Visit to find out what they are.

Community-based Care Transition 3026 Grants Awarded to Massachusetts Partnering Organizations

In August 8th 2012 the Center for Medicare and Medicaid Services (CMS) announced the third round of site selections under the Community-based Care Transition Program (CCTP), 3026 grant offered through the Affordable Care Act (ACA), which provides funding from the Innovation Center to community-based organizations partnering with eligible hospitals for care transition services.  Awardees of this grant will be charged with improving care transitions from the hospital to other settings and reducing readmissions for high-risk Medicare beneficiaries. The 3026 grant is part of the Partnership for Patients and is charged with reducing hospital-acquired conditions by 40% and hospital readmissions by 20% by 2013.  Community-based organizations will use care transition services to effectively manage Medicare patients' transitions and improve their quality of care. Up to $500 million in total funding is available for 2011 through 2015. Learn more about CCTP.

Under the ACA there were 17 national sites awarded a grant in August 2012, and joined the already 30 national sites announced in November 2011 and March 2012.  Massachusetts to date has been awarded 4 of the grants for our partnering organizations which are located throughout the state. The partnering organizations will be working with CMS and local hospitals to provide support for high-risk Medicare patients following a hospital discharge as they move to new settings, including skilled nursing facilities and home health services.  The Massachusetts CCTP grand awardees for Massachusetts are listed below:

August 2012 recipient:

1. Somerville-Cambridge Elder Services, a Massachusetts-designated Aging Services Access Point (ASAP) and an Area Agency on Aging (AAA), will partner with Mystic Valley Elder Services, Cambridge Health Alliance, Hallmark Health System and dozens of community-based health and social service providers to provide care transitions services in Middlesex County.

March 2012 recipients:

1. Elder Services of Berkshire County, a Massachusetts-designated (ASAP) and federally-designated AAA in rural western Massachusetts, that has partnered with Berkshire Medical Center and the Berkshire Visiting Nurse Association to improve care transition services for Medicare beneficiaries.

2. Elder Services of Worcester, Massachusetts, a Massachusetts-designated ASAP and federally-designated AAA, that has partnered with Bay Path Elder Services. They will provide care transitions services in partnership with seven hospitals, including: MetroWest Medical Center; St. Vincent Hospital; UMass Memorial Medical Center; Wing Memorial Hospital; Marlborough Hospital; Clinton Hospital, and HealthAlliance Hospital.
November 2011 recipient:

1. Elder Services of the Merrimack Valley, Inc., in partnership with Anna Jacques Hospital, Saints Medical Center, Holy Family Hospital, Lawrence General Hospital, and Merrimack Valley Hospital, and serving 23 cities/towns in the Merrimack Valley of Massachusetts and ten bordering cities/towns in southern New Hampshire where patients using these hospitals also reside.


A Gatefold Publication You Can Use 

One of MHA's Strategic Performance Improvement Priorities - reducing preventable readmissions - is garnering great attention in 2011. Hospital Boards of Trustees throughout Massachusetts are signing on to the three-part improvement initiative in which they pledge to address the issues of readmissions, mortality, and central line-associated bloodstream infections at their regular meetings; to advocate for healthcare policies that reduce incidences of the three issues; and to measure improvements in the three areas.

In February 2011, nearly 400 caregivers attended a two-day STAAR conference - or State Action on Avoidable Readmissions. STAAR is focused on improving care transitions to reduce readmissions. Twenty-two cross-continuum teams have been part of the STAAR project since September 2009, and 27 new teams came to the event to learn from their colleagues and begin their own work.

On the state and federal level, Medicaid and Medicare are, or are about to, institute penalties for excessive readmissions.

Now, Hospitals & Health Networks, the flagship publication of the American Hospital Association has produced this "Gatefold" publication on the readmissions issue. It lays out the numbers, key aspects of the Affordable Care Act relating to readmissions, the top seven hospital readmissions, and a checklist that STAAR states, such as Massachusetts, use to assess and remedy the problem.




Reducing Readmission Top Ten, Evidence Based Interventions



HRETs Readmissions Change Package - Improving Care Transitions & Reducing Readmissions - 2014 Update


Eliminate Harm Across the Board - HRET's Readmissions Poster



Reducing Readmissions: Highlights/Specific Tools from Massachusetts STAAR Cross-Continuum Teams

For the past three years, the Massachusetts Hospital Association (MHA) and the Massachusetts Coalition for the Prevention of Medical Errors (the Coalition) have been working with partner organizations and with cross- continuum teams to reduce avoidable readmissions within Massachusetts and improve care transitions for patients and families.

Download Highlights and Specific Tools from Massachusetts STAAR Cross-Continuum Teams

HRET Action Guide to Reduce Avoidable Readmissions

Reducing avoidable hospital readmissions is an opportunity to improve quality and reduce costs in the health care system. This guide is designed to serve as a starting point for hospital leaders to assess, prioritize, implement, and monitor strategies to reduce avoidable readmissions.

Download HRET Action Guide

State Plan for Care Transitions

Under the auspices of the Massachusetts Statewide Quality Improvement Initiative (SQII), a task force developed a State Plan for Care Transitions. It is designed to be a useful tool for the Massachusetts healthcare community to realize a vision of integrated, high-quality, coordinated, and efficient health care delivery.

Healthcare Quality/Readmissions Issues Brief

Massachusetts is currently participating in many projects to address and improve hospital readmission issues. A summary of these projects follows.

Read More (PDF) »

STate Action on Avoidable Rehospitalizations Initiative (STAAR)

A multi-state project involving 53 hospitals, STARR was launched by the Institute of Healthcare Improvement (IHI) in May 2009 with grant funding from The Commonwealth Fund. 22 Massachusetts hospitals are enrolled in the initiative. To date, participating hospitals have formed cross-continuum teams and submitted baseline 30-day readmission rates. Now they are busy determining how to improve the patient's transition from hospital to post-acute setting.

Read More »