Care Coordination

Reduce Unnecessary Readmissions

Readmissions to hospitals within 30 days of discharge occur in nearly 20 percent of patients in the United States. Up to 76 percent of those readmissions could be prevented, resulting in better quality of life and lower healthcare costs.

Communities in Maryland and Virginia are working with Health Quality Innovators (HQI) to reduce avoidable readmissions and ensure that Medicare beneficiaries can maintain their health at home. This initiative relies on a community-based approach in which clinical providers (hospitals, nursing facilities, home health agencies, pharmacies, etc.), community service organizations, patients, advocates and others work collaboratively to create an effective, local system for coordinating post-hospital care.

Participants receive technical assistance from HQI to build community coalitions, identify the root causes of readmissions, analyze data and select effective interventions.

Adverse Drug Events

Adverse Drug Events (ADEs) are a leading cause of preventable patient harm and contribute to avoidable hospital readmissions. The most vulnerable patients take multiple medications, including high risk medications. HQI works with care transitions communities to monitor and reduce the rate of ADEs across the continuum of care. The primary focus of ADE interventions are with patients taking diabetes medication, blood thinners, or opioids and are on three or more medications.

HQI is engaging communities of clinical and local service/support partners to improve care for Medicare beneficiaries.

Goals include:

  • Reducing 30-day re-hospitalizations by 20%
  • Reducing overall hospitalizations by 20%
  • Increasing the number of nights beneficiaries spend at “home” by 10%
  • Reducing adverse drug events (ADEs) by 35%
  • Sustaining greater than 60% of each community’s interventions.
  • Building community capacity to qualify for formal program or grant funding
  • Spreading successful and innovative practices

To learn more, contact Carla Thomas at or Kelly Arthur at