Reduction of avoidable hospital readmissions is critically important to improve quality of patient care and meet anticipated changes in the Centers for Medicare and Medicaid Services’ (CMS) payment reimbursements as part of the Affordable Care Act (ACA). This session will outline the key elements of a successful program at a large community acute care hospital to decrease 30-day hospital readmissions. Speakers will present data demonstrating the program’s successful impact on readmission rates and describe effective strategies to secure administrative "buy-in" and identify patients at high risk for hospital readmission. The speakers will explain how to define and implement the role of a Transition Care Coach.

Learning Objectives:
1. Explain the importance of a readmission prevention program

2. Implement tools and strategies for identification of patients at risk for readmission

3. Develop multi-disciplinary and community collaboration to improve patient transitions and reduce hospital readmissions