CHAMP QI-Tip of the Month: Using Improvement to Reduce Readmissions

By Jane Taylor, CHAMP Improvement Advisor

A key tenant in improvement work is to try changes on a small scale in order to understand how and if the change will work, and to evaluate if it really is an improvement. This is called a “small test of change” or a Plan, Do, Study, Act cycle (click here for a set of slides summarizing the PDSA Cycle, and click here for a PDSA worksheet).

My challenge to you this month is to try some changes that can help prevent your patients from being readmitted.

Of course, there are many changes you can test, but here are a few suggestions to get you started:

Teach Back

You can do a small test of change around Teach Back (see my QI-Tip, “Try It On Before You Buy It”), or just try Teach Back on your next admission and see what happens. If the patient is not capable of learning how to care for themselves, use Teach Back with a caregiver. To assess whether the patient or caregiver can teach back, ask them how they would explain aspects of their care to a neighbor or family member, including how and when they should take their medicines, when they should call the doctor, and where to find emergency phone numbers. Can they do it? If not, the patient is at risk for a readmission. How many visits does it take until the patient or designated learner can teach back all the items needed to help manage their condition or illness? For more on Teach Back, watch this video.

Medication Management

Some of the very best changes can be found in the materials for CHAMP’s Geriatric Medication Management course for frontline managers, including tools and strategies to help better reconcile home meds, identify potentially dangerous interactions or duplications, and check that medications are appropriate for older home care patients. Frontline managers can register for the course and anyone can access free tools from the Tools page of CHAMP’s Resource Library (just select “Medication Management” from the ‘All Topics’ drop-down menu). Or just come up with your own ideas for how your department or agency can make improvements in medication management.

The Warm Handover* – Getting the Information You Need from Hospitals

A good change is to try to get a warm handover from the discharging hospital (i.e., getting information directly from the hospital about the latest hospital episode for patients you are admitting). The warm handover is most effective if it includes voice-to-voice communication between the actual hospital and home health professionals that have cared for (or will care for) the patient. You may think this is impossible because information usually comes to the admission nurses at your agency. But what if you did a test where, on the next admission call, the intake person at your agency conferences you in to hear about the patient?

What if you work with the hospital and put your “asks” out there? “This is the vital information we need to provide great care. Can you, oh hospital, give it to us each and every time you send us a patient?”

Right now, according to the Transitions of Care Consensus Policy Statement, the following information, at minimum, should always be provided to you as part of the transition record:

  • A principal diagnosis and problem list
  • A medication list (reconciliation), including over-the counter medications/herbals, allergies, and drug interactions
  • The medical home/transferring coordinating physician/institution name and contact information, clearly identified
  • The patient’s cognitive status
  • All test results and pending results

If you need other information (see the Statement for suggested additional information), let the hospital know what it is!


Think about how your agency might collaborate with a local hospital or physicians group to reduce readmissions. In an initiative called STAAR (STate Action on Avoidable Rehospitalizations) — part the great work the Commonwealth Fund and the Institute for Healthcare Improvement (IHI) are doing to reduce readmissions — home health agencies, physician practices and hospitals team up to create a common, agreed upon set of simple teaching materials, so patients and family members are not confused by a multiple explanations and instructions. (Refer to and search under reducing readmissions).

Again, this is not an exhaustive list. If you have other ideas (or if you test any of the changes above), please tell us about it by posting a comment below.

Good Luck and Happy Testing!

* In working on readmissions, the Michigan Hospital Association introduced me to the term “handover.” They felt that “handoff” implied being completely finished with a patient and handing them “off,” and that “handover” was a more positive and descriptive term. I adopted the term “handover,” as have others.


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