Care Coordination, Readmissions - Qsource


One in five adults aged 65 and older is discharged from the hospital only to be readmitted again. The issue involves multiple providers across several settings. We must understand not only what is going on within hospital walls, but also what is taking place after patients leave.

Main causes of readmissions include

  • Poor information transfer or communication between providers
  • Decreased patient and family involvement
  • Underutilized support services to assist with activities of daily living
  • Multiple chronic health conditions

Qsource is bringing together state-wide communities to create powerful collaborations of change. These communities are united in the goals to

  • reduce hospital readmission and admission rates in the Medicare program by 20 percent by 2019 and
  • increase the patient’s time spent at home after discharge by 10 percent.

Join a community today to get started.


Featured Resource

Use the tabs to the right to search for specific tools and resources related to this page.

You can also search our comprehensive library of online resources, where you can sort by Qsource state, initiative, patient or provider focus or simply type in a keyword for quick access to the tools and resources you need.

Guide to Preventing Readmissions among Racially and Ethnically Diverse Medicare Beneficiaries
IOM Roundtable on Health Literacy: Ten Attributes of Health Literate Health Care Organizations
Discussion paper highlights findings to determine ten attributes of health-literate healthcare organizations
In Plain Words
Creating easy-to-read handouts
The Harvard School of Public Health: Health Literacy Studies
Information and tools on developing and assessing innovative materials
CDC Toolkit for Long-Term Care Employers: Seasonal Flu
Provides resources to help long-term care facility, agency or corporation owners and administrators provide access to influenza vaccination for their workforce and to help any employer of workers in long-term care understand the importance of influenza vaccination for their employees
HHS/Healthy People 2020: Social Determinants of Health
Resource offers an overview of Healthy People 2020 objectives, as well as national and local resources and data on key determinants of health.
AHRQ Quality Indicators™ Toolkit for Hospitals
This toolkit is designed to help hospitals understand the Quality Indicators (QIs) from AHRQ and use them to successfully improve quality and patient safety.
Hospital Guide to Reducing Medicaid Readmissions
The Agency for Healthcare Research and Quality (AHRQ) commissioned this guide to identify ways evidence-based strategies to reduce readmissions can be adapted or expanded to better address the transitional care needs of the adult Medicaid population.
Next Step in Care
Provides easy to use guides to help caregivers and healthcare providers work closely to plan and implement smooth transitions for chronically or seriously ill patients
Aims to build a healthcare system that can find patients who are living with serious and complex illness, tailor services to their priorities, and plan and pay providers in a way that encourages quality care at a price that communities and families can bear
Health Information in Multiple Languages: MedlinePlus
Offers access to high quality health information for patients in 40 languages; more than 2,500 links to nearly 250 health topics
Better Outcomes for Older Adults through Safe Transitions (BOOST)
BOOSTing Care Transitions implementation toolkit with materials to help optimize the discharge process
Continuity of Care for Suicide Prevention: The Role of Emergency Departments
Paper highlights key steps emergency department (ED) providers can take to establish continuity of care for patients at risk for suicide
Readmissions Penalties by State (Year 3)—Kaiser Health News
Kentucky Department for Aging and Independent Living
The National Consumer Voice
Agency for Healthcare Research and Quality
Community-Based Care Transition Program
Hospital Compare
Nursing Home Compare
Taking Charge of Your Healthcare
The Conversation Project
AHRQ Health Literacy
The Alliance to Advance Patient Nutrition
The Empowered Patient Coalition
Care Transitions Program
Home Health Quality Improvement (HHQI) Campaign
Center to Advance Palliative Care
National Transitions of Care Coalition
The Dartmouth Atlas of Healthcare
Medline Plus: Health Information in Multiple Languages
Medline Plus: End of Life Issues
Ask Me 3
Why Not the Best: QI Resources for Healthcare Professionals
The Gift Initiative
The Center for Excellence in Assisted Living
Figaro: Donna, Nicki & Bill – Caregiver Assistance
AARP’s contest-winning video tells the story of family caregiving through a short film.
Honoring Choices Wisconsin
Wisconsin Medical Society promotes the benefits of improving processes for advance care planning across the state in healthcare settings and in the community
CDC Vital Signs: Stop the Spread of Antibiotic Resistance
AHRQ Patient Safety Videos – Featuring CUSP and TeamSTEPPS
KATS: Kentucky Appalachian Transition Services
See how one community of healthcare providers in Kentucky is focused on reducing hospital readmissions for patients with Medicare and is succeeding in improving patient care.
What Is Palliative Care?
Logic Models
The QIO Program helps you embrace data in your healthcare setting
Failure Modes & Effects Analysis (FMEA)
The QIO Program shares 5 steps in the Failure Modes and Effects Analysis (FMEA) to anticipate potential problems before they occur
Root Cause Analysis (RCA)
The QIO Program demonstrates how to identify the root cause of a problem using The 5 Whys
An Illustrated Look at QI in Healthcare
QIO Documentary
Learn about the history of the QIO Program, from 1966 through today.
IHI Whiteboard: Model for Improvement, Clip 1
IHI Whiteboard: Model for Improvement, Clip 2
IHI Whiteboard: PDSA Cycles, Part 1
IHI Whiteboard: PDSA Cycles, Part 2
IHI Whiteboard: Cause & Effect Diagrams
Video: Domestic Lean Goddess PDSA

Readmissions Blog

  • Creative Ways to Teach Infection Prevention in Nursing Homes

    Creative Ways to Teach Infection Prevention in Nursing Homes

    Creative Ways to Teach Infection Prevention in Nursing Homes All staff members in a nursing home play an important role in keeping residents safe from infections. They should know some basics about the germs (like bacteria and viruses) which cause infections. They should also know steps they can take to prevent the spread of germs…
  • From the Center of My Care Team

    From the Center of My Care Team

    From the Center of My Care Team by Janet Pollock, Kentucky In 2002, I began an exciting career journey with the Kentucky Quality Improvement Organization (QIO). During my early days with the QIO, my focus was outreach – teaching Medicare beneficiaries about their benefits, when and how to file a complaint, and what to expect…
  • Improving Patient Education to Prevent Adverse Drug Events

    Improving Patient Education to Prevent Adverse Drug Events

    Improving Patient Education to Prevent Adverse Drug Events Anticoagulant medications such as warfarin and heparin are among the most common medications that cause complications for people in the hospital, according to the American Journal of Medicine. But maximizing communications across the care continuum and engaging patients and family members can prevent these life-threatening events. Qsource…

Blog Archive

Care Coordination, Interventions - Qsource


We work with providers within their communities to help them select evidence-based interventions associated with known causes of readmission. Put them to work in your facility.

Care Coordination, Adverse Drug Events - Qsource

Adverse Drug Events

Adverse drug events are a leading cause of preventable patient harm. Learn what you can do to prevent them.

Care Coordination, Communities - Qsource


Communities across the country are working together to improve care coordination for Medicare beneficiaries in Tennessee. Get involved today.