Maintaining patient health after a hospital stay...
RARE - Reducing Avoidable Readmissions Effectively

Patient and Family Engagement

Patient/family discharge preparation is one of five key areas known to reduce avoidable readmissions. Hospitals working on this topic will focus on ensuring that processes are in place to engage patients/family, elevate the status of family caregivers as essential members of the team, and prepare the patient and family to manage care at home. Interventions may include such methodologies as teach back, collaborative conversations and communication, and simulations with the patient and family member. Studies have shown patient engagement is central to improving readmission rates. Hospitals that ensure patients are able to self-manage their conditions have better outcomes; informed patients are prepared for procedures and hospitalizations' and patient education at discharge can reduce the relative risk of readmission.

Patient and Family Engagement - Tools and Resources >

Typical Transition Failures


  • Unrealistic optimism of patient and family to manage at home
  • Patient lack of adherence to self-care, (e.g., medications, therapies, daily weights, or wound care) because of poor understanding or confusion about needed care, transportation, how to schedule appointments, or how to obtain or pay for medications
  • Multiple drugs exceed patient's ability to manage

Care Planning

  • Failure to actively include the patient and family caregivers in identifying needs and resources, and planning for the discharge
  • Lack of understanding of the patient's physical and cognitive functional health status that may result in a transfer to a care setting that does not meet the patient's needs
  • The care provided by the facility unravels as the patient leaves the hospital (i.e., poorly understood cognition issues emerge)
  • Multiple care providers; patient believes someone is in charge

Health Literacy/Communication

  • Patient/family failure to ask clarifying questions on instructions and plan of care

Best Practices/Strategies for Improvement


  • Conduct pre-discharge assessment of ability of patient/family to provide self-care (includes problem solving, decision making, early symptom recognition, and taking action, quality of life, depression other cognitive factors)
  • Provide pre-discharge condition specific education
  • Conduct post-discharge telephone care management

Care Planning

  • Work with patient/family for prepare for the post-discharge visit planning (goals, questions, concerns)
  • Develop a comprehensive shared care plan using a shared decision making approach – consider patient values and preferences, social and medical needs
  • Use personal health records or patient portals so patients have access to necessary information (lab results, radiology results, request prescription refills, ability to email doctors, nurses, and staff with questions)

Health Literacy/Patient-Provider Communication

  • Embed health literacy principles into all patient education and interactions.
  • Employ the teach-back method to ensure patients/families understand information and explanations given and that their questions are answered
  • Provide culturally and linguistically appropriate care
  • Ensure continuity in care in order to build trust
  • Use a shared decision making approach
  • Ensure enough time is available for consultation

Proposed Process or Outcome Measures

  • Discharge instructions include warning signs and symptoms
  • Discharge instructions include who to call if warning signs and symptoms
  • Teach back for patient education is documented
  • Patients with more than five prescribed medications (polypharmacy) are referred for follow up/pharmacy/medication management
  • Electronic copy of health information is provided to patients; discharge summary and procedures for hospitals
  • Post-discharge follow-up call is made within 24 hours of discharge
  • Percentage reached by follow-up phone call within 24 hours of discharge
  • Follow-up appointment occurs within a specified number of days of discharge
  • Medication reconciliation occurs within a specified number of days of discharge
  • Provide summary of care record for patients referred or transitioned to another provider setting
Patients and family members
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RARE is a campaign lead by the Institute for Clinical Systems Improvement, the Minnesota Hospital Association, and Stratis Health, which represents Lake Superior Quality Innovation Network in Minnesota.