Improving transitions to reduce readmissions.

Delivering high quality healthcare requires crucial contributions from many parts of the care continuum. However, as healthcare becomes increasingly specialized, coordination between providers and between settings is too often not conducted as a team effort. In the hospital setting, poor coordination of care often results in hospital readmissions, many of which are avoidable. In this article, we describe processes that hospitals can implement immediately to dramatically improve care transitions and reduce re-hospitalization rates. Readmission rates are a focus of interest for payers and policymakers seeking to promote efficiency and quality. Hospital executives may want to prepare their organization to excel on this performance metric in anticipation of payment, policy, and/or other forecasted changes in the market.