Illustration of Two Doctors Attending to a Patient in a Hospital Bed in the Emergency Department

Readmitting patients within thirty days of when they were last discharged costs hospitals an average of $17,000 per patient and represents a huge cost to the health care system. To reduce readmissions, the federal government has been penalizing hospitals for excessive readmissions for over a decade. The Centers for Medicare and Medicaid Services (CMS) estimates penalties levied on the healthcare system in 2022 alone could have been reduced by $521 million dollars by reducing avoidable readmissions (1).

In addition to the cost and penalties associated with readmissions, a high rate of patient readmissions may indicate inadequate quality of care in the hospital and/or a lack of appropriate post-discharge planning and care coordination. Unplanned readmissions are associated with increased mortality, decreased patient experience, and higher health care costs. The good news is readmissions can be prevented by standardizing and improving coordination of care after discharge and increasing support for patient self-management (2). Thus, reducing hospital readmissions is one of OneCare’s 21 priority annual quality measures.

OneCare’s quality team worked alongside Northwestern Medical Center (NMC) in St. Albans to determine that reducing hospital readmissions was an opportunity to reduce cost and improve quality. The Medicare readmission rate for the St. Albans Health Service Area is 15.27%, which is higher than the national average of 14.0% reported by the Agency for Healthcare Research and Quality (AHRQ) for 2018.

OneCare supported NMC as they conducted a gap analysis to identify workflows and data collection practices for potential improvement. In alignment with national best practices, better management of transitions of care was identified as one overall opportunity.

Having OneCare be part of our collective improvement around transitions of care has been invaluable to our community. The Quality Improvement Specialist at OneCare has helped us stay focused on implementing small changes in our systems to make big improvement in transitioning patients from one setting to another.

Denise Smith

Director of Population Health Programs and Strategy, Northwestern Medical Center

To manage transitions better, NMC has identified the following areas of opportunity:

  • Improve documentation of care during the inpatient stay.
  • Prioritize patient care discussions between teams and patients, leading to better communication overall to aid in ensuring the right strategies are put into action for each individual patient.
  • Establish an adequate post discharge support system for patients
  • Create a community level “Transitions of Care Committee” to support patients to get the care and support for their social determinants of health.
  • Schedule patients to see their primary care provider 7 days after their hospitalization.
  • Flag COPD (chronic obstructive pulmonary disease) and CHF (congestive heart failure) patients over 65 as high risk in the electronic medical record (EMR) system so the team can work toward a standardized approach to care across the continuum for these populations.
  • Establish a monthly work group tasked with improving transitions of care to external partners. 

Example of putting evidence-based strategies into action:

Increased patient mobility and activity during hospitalization has been linked to reduced readmissions because strength is maintained by avoiding functional loss, medical complications, and/or hospital acquired deconditioning. Therefore, NMC’s rehabilitation department is actively working with its nursing staff on identifying mobility and activity levels to better communicate opportunities for patient mobility programs for patients who may otherwise miss out on getting mobility and activity because their other symptoms/reason for admission didn’t prompt them to be seen by a rehabilitation therapist.


Early indications from NMC’s electronic medical record (EMR) are positive, though they are still in the early stages of identifying and implementing changes. Northwestern Medical Center’s care management team is tracking their success identifying primary care physicians and patient care partners, completions of patients seen on date of discharge, and primary care physician office appointments scheduled prior to patient transition from NMC.

This project highlights how OneCare supports local quality improvements in Vermont’s Health Service Areas (HSAs) through data sharing and interpretation to identify areas of improvement and facilitate that improvement. With OneCare’s help, NMC was able to identify the opportunity for improvement and implement a strategy for success. They are now bringing together partners from across the hospital with plans to further incorporate home health and hospice and skilled nursing facilities, leading to reduced cost for the hospital and improved patient experience.

For more information

Please contact Public Affairs at OneCare Vermont. | 802-847-1346

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