Care Coordination

Improving Care Coordination by Reducing Readmissions

Reducing 30-day readmissions and minimizing unnecessary emergency department visits remain top priorities for the Centers for Medicare & Medicaid Services (CMS), underscored by initiatives such as the Hospital Readmission Reduction Program (HRRP). Hospital readmissions are a critical measure of the quality of care provided and contribute significantly to Medicare costs, estimated at $52 billion annually (AHRQ, 2018). A few of the drivers of unplanned hospital readmissions include communication breakdowns during transitions of care, clinical factors, health literacy, delayed end-of-life conversations and social determinants of health.

Certain demographic groups are disproportionately affected by readmissions and emergency department visits due to factors like public policies, social disparities and biases, leading to what is termed as readmission disparities (CMS, 2020). Exploring the underlying causes of these disparities can enhance health outcomes for Medicare beneficiaries, particularly the vulnerable, while also aiding in controlling costs associated with readmissions.

How Telligen is Improving Care Coordination

We offer a multi-pronged approach to address key components to improve care coordination and decrease hospital admissions and readmissions, incorporating evidence-based interventions and best practices, data-driven improvements and stakeholder collaboration.

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Healthcare Readmission Disparty Data

Hospital Readmissions Icon

Black Americans are 106% more likely to be readmitted to the hospital compared to white Americans.

Data analysis reveals significant disparities in healthcare readmissions, particularly evident in racial and ethnic breakdowns. Based on Telligen claims data collected in Colorado, Illinois, Iowa and Oklahoma, Black Americans exhibit a 106% higher likelihood of hospital readmission compared to their white counterparts.

Interventions to Reduce Readmissions

State-Specific Signed Medical Orders
    • A signed medical order for documenting the life-sustaining treatment wishes of patients in Colorado
    • A signed medical order for documenting the life-sustaining treatment wishes of patients in Illinois
    • A signed medical order for documenting the life-sustaining treatment wishes of patients in Iowa
    • A signed medical order for documenting the life-sustaining treatment wishes of patients in Oklahoma
Teach-back is a technique for healthcare providers to ensure that they have explained medical information clearly so that patients and their families understand what is communicated to them. This intervention includes several materials to support adoption.
Telligen's Quality Improvement Workbook

In this workbook you will find valuable resources to support your team’s quality improvement efforts, including an interactive timeline to follow, quality improvement goal statement template and ways to track progress during your organization’s quality improvement journey.

Transitional Care Management for Skilled Nursing Facilities and Hospitals

Learn about Transitional Care Management Services with this Medicare Learning Network booklet

Nursing Home Interventions


Interventions to Reduce Acute Care Transfers (INTERACT®) is a quality improvement program that focuses on the management of acute change in resident condition. It includes clinical and educational tools and strategies for use in everyday practice in long-term care facilities.

Decision Guide

Go to the Hospital or Stay Here? A Decision Guide for Patients and Families

Did you know that almost half of transfers to the hospital may be avoidable? This guide will help you understand why these transfers are made and how you can be involved in
the decision.

Hospital Interventions

AHRQ Health Literacy Toolkit
The AHRQ Health Literacy Universal Precautions Toolkit can help primary care practices reduce the complexity of healthcare, increase patient understanding of health information, and enhance support for patients of all health literacy levels.

ASPIRE – This guide from AHRQ identifies ways evidence-based strategies to reduce readmissions can be adapted or expanded to better address the transitional care needs of the adult Medicaid population.

Five Wishes

Five Wishes is advance care planning that is written in everyday language, making it easy to understand and complete. It covers personal, spiritual, medical and legal wishes all in one document and allows families or caregivers to know exactly what their family member wants.

*Five Wishes is not a free service.

Guide to Reducing Disparities in Readmissions

The Guide to Reducing Disparities in Readmissions provides clear, concise, practical, and actionable recommendations for hospital leaders such as CEOs, VPs, team leads, and others who focus on health care quality, safety, and redesign. This guide is aligned with the goals of the CMS Partnership for Patients focused on improving care transitions, reducing 30-day hospital readmissions, making care safer, and reducing costs.


I-PASS has become the preferred handoff tool for patient transitions in many organizations. It is an example of an evidence-based option for conducting a structured handoff. Your facility should determine a standard protocol for delivering handoffs and make it known to everyone.

Medications at Transitions and Clinical Handoffs (MATCH) Toolkit

Medication reconciliation is a complex process that impacts all patients as they move through all healthcare settings. The process involves comparison of a patient’s current medication regimen against a physician’s admission, transfer, or discharge orders to identify discrepancies. Study data show that an effective process can detect and avert most medication discrepancies, potentially avoiding a large number of adverse drug events and related costs for care of affected patients. This toolkit incorporates the experiences and lessons learned by health care facilities that have implemented the MATCH strategies to improve their medication reconciliation processes.

MVP Method

The MVP Method is a delivery system transformation strategy developed to deliver more effective care to patients experiencing a cycle of high utilization of the hospital or emergency department. Developed by Dr. Amy Boutwell, she drew from the best of what has worked for the most teams in the widest variety of settings based on her work over the past 12 years leading delivery system transformation initiatives to improve care and deliver value by reducing recurrent acute-care use. The MVP Method has been implemented by over 275 healthcare teams in 40 states, making it the most widely disseminated high utilizer strategy in the United States.

Patient Safety Movement Tools
Project BOOST®

Project BOOST® (Better Outcomes by Optimizing Safe Transitions), the Society of Hospital Medicine’s signature mentored program, serves as a national model for improving the quality of care and reducing hospital readmissions. Download the Project BOOST® Implementation Guide.

Project RED

Project RED – Project Re-Engineered Discharge (RED) develops and tests strategies to improve the hospital discharge process in a way that promotes patient safety and reduces re-hospitalization rates.

Readmission & Multi-Admission Patient Reduction Learning Collaborative Workbook

This workbook will help develop an individualized, multidisciplinary program with goals, process and outcome measures aimed at preventing hospital readmissions and reducing multi-admission patient utilization.

Targeted Solutions Tool

The Targeted Solutions Tool® (TST) is an online application that guides healthcare organizations through a step-by-step process to accurately measure their organization’s true performance level, identify the causes of performance failures, and direct them to proven solutions that are customized to address their particular causes. A TST module is available for improving hand hygiene.

Collaborating to Improve Care Coordination

Through a collaborative quality improvement project, Telligen helped partners identify drivers leading to rehospitalization and used data to improve processes. Through education on quality improvement methodology, rehospitalization rates were addressed and organizations were presented with attainable action items and experienced positive outcomes. 

“Participating in the University of Iowa PACC and Telligen monthly meetings was extremely beneficial in our quality improvement plan. The tools and resources provided have been integral in helping us identify strategies for success.”

– Scott Maiers, Community Relations Director at Solon Retirement Village

Telligen Services

Telligen uses a multi-pronged approach to address key components to improve care coordination and decrease hospital admissions and readmissions, incorporating evidence-based interventions and best practices, data-driven improvements and stakeholder collaboration.


Enhanced Technical Assistance (TA)

    • We use our knowledge and experience to help clients summarize and synthesize evidence-based practices and their own data to generate insights and actionable strategies to inform decision-making and accelerate improvement.
    • Request one-on-one enhanced technical assistance today!

Secure Portal

    • The Telligen QI Connect™ Secure Portal offers:
    • Medicare data on quarterly readmission rates of their specific community
    • Aggregated data from other data sources (­i.e., public data, self-reported data)
    • Telligen community maps
    • Learning management system
    • Tools/resources

Learning and Action Networks (LANs)

    • LANs are regionally-focused improvement tools bringing together healthcare professionals, patients and other stakeholders around an educational, evidence-based agenda to achieve rapid, wide-scale healthcare improvement.
    • View our calendar of events here.

Community Coalitions

    • A community coalition is a formal, long-term alliance of organizations, groups and agencies that come together to work toward a common goal, such as reducing avoidable hospital readmissions.
    Elderly Care

    Who We Help

    nursing homes



    community partners

    patients & families