Abstract
Abstract: Unplanned hospital readmissions are common and often preventable. A review of Medicare discharge data identified a geographical area with higher than expected readmission rates. The state Medicare quality improvement organization (QIO) used community organizing techniques to assess provider engagement and hypothesized that a small workgroup of high impact providers could address some root causes for preventable readmissions, achieve quick wins, and reinvigorate the broader community-wide coalition. Seven of the eight facilities targeted by the QIO actively engaged and began rapid cycle initiatives to improve the patient transfer process between providers. Monthly, 2-hr structured meetings were supplemented by additional ad hoc meetings convened by participants. Effectiveness of the intervention was measured by workgroup functioning, the implementation of multiple initiatives spread from the small workgroup to the broader provider coalition, and reductions in readmissions to the anchor hospital system from the participating skilled nursing facilities. The community impact of the workgroup initiative is shown by a decline in community readmission rates for Medicare beneficiaries.