Reducing Readmissions Part 5: Best Practices and Future Directions

Course overview

This course traces the evolution of readmission prevention from a compliance penalty under the Hospital Readmissions Reduction Program (HRRP) to a comprehensive, value-based strategy focused on quality and health equity. It highlights evidence-based transitional care models, such as Project RED and CTI, and emphasizes the crucial role of community resources, including community health workers (CHWs), in bridging the gap between hospital and home. The presentation then explores how technology specifically AI and predictive analytics, natural language processing (NLP), and telehealth accelerates these efforts, while dedicating an entire section to the critical need for pharmacist-led medication management (including Meds-to-Beds programs) to prevent medication-related readmissions. Finally, it positions the case manager as a future-focused leader who must acquire new competencies in digital fluency and trauma-informed care to navigate the shift toward hybrid, home-based, and value-based care models.