Readmission reduction takes center stage.

As penalties for excess readmissions rise and more diagnoses are included in the program, case managers can play a major role in helping their hospitals avoid penalties. Take the time to complete a thorough assessment of patients and talk to their family members and caregivers to uncover psychosocial issues as well as medical issues and use the information to develop the discharge plan. Collaborate with post-acute providers to ensure that patients receive the services they need after discharge. When patients are readmitted, conduct a root-cause analysis to determine why they came back, track the data, and use it to develop process improvement projects.