Reducing Readmissions Part 2: Evidence-Based Strategies
Presented by Colleen Morley
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This course is designed to equip learners with the knowledge to identify and apply major evidence-based models, such as Project RED, the Care Transitions Intervention (CTI), and Project BOOST, to reduce hospital readmissions. A core component of the training is the application of risk stratification tools like LACE, HOSPITAL, and PATIENT scores to efficiently target high-risk patients with appropriate interventions. Finally, the course examines common implementation barriers, like organizational silos and communication gaps, and provides strategies for integrating these practices into transitional care and case management workflows, reinforcing the case manager’s essential role in leading these quality improvement efforts.
Learning Objectives
- Identify major evidence-based models that support hospital readmission reduction
- Evaluate the effectiveness of interventions like Project RED, the Care Transitions Intervention (CTI), and Project BOOST in applied clinical settings
- Apply risk stratification tools (e.g., LACE, HOSPITAL, and PATIENT scores) to recognize individuals at elevated risk for readmission
- Examine common barriers to implementing readmission reduction strategies and potential approaches for addressing each barrier
- Integrate evidence-based practices for readmission prevention into transitional care and case management workflows
Meet your instructor
Colleen Morley
Dr. Colleen Morley has held positions in acute care as director of case management at several acute care facilities and managed care entities in Illinois, overseeing utilization review, case management, and social services for more than 12 years and piloting quality improvement initiatives focused on readmission reduction and…
Chapters & learning objectives
1. Why Evidence-Based Strategies Matter
Chapter 1 establishes the importance of evidence-based practice (EBP) in reducing avoidable hospital readmissions, improving patient satisfaction, and generating cost savings by ensuring interventions are data-driven and consistent.
2. Major Readmission Reduction Models
This chapter reviews the foundational evidence-based programs—such as Project RED, Project BOOST, the Naylor Transitional Care Model (TCM), CTI, and INTERACT—detailing their core components, target populations, and proven effectiveness in reducing readmissions.
3. Risk Stratification in Readmission Reduction
In this chapter, Dr. Morley explains how to use validated tools like the LACE, HOSPITAL, and PATIENT scores to efficiently identify individuals at the highest risk for readmission and tailor the intensity of transitional care interventions to their specific needs.
4. Implementation Challenges and Integration Into Case Management
The final chapter of this course explores common barriers to successful implementation (e.g., organizational silos and communication gaps) and outlines strategies for integrating EBP, using tools like EMR prompts and checklists, to sustain readmission reduction efforts led by the case manager.
5. Question and Answer Session
In this chapter, Colleen Morley will address common questions about reducing readmissions.
More courses in this series
Reducing Readmissions Part 1: Understanding the Landscape
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Reducing Readmissions Part 2: Evidence-Based Strategies
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Reducing Readmissions Part 3: Social Determinants of Health
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Reducing Readmissions Part 4: The Case Manager’s Role
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Reducing Readmissions Part 5: Best Practices and Future Directions
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