Pharmacy OneSource Blog

A Multi-Stakeholder Approach to Preventing Hospital Readmissions

These include identifying patients at high risk of readmissions, greater patient engagement in education, and improved communication. A report by the group also recommends shared accountability that does not leave the full burden of reducing readmissions on hospitals, but involves health plans in the effort and financial investment as well.

A multi-stakeholder approach includes three essential elements:

  • Collaboration in clinical outreach and care: Both hospitals and health plans frequently implement plans that stratify patients by risk and provide focused attention and special services to those at highest risk of readmission. Often, however, their efforts run in parallel or duplicate each other’s efforts, wasting money and leaving patients confused about what they should do and with whom they should follow up. Integration of risk identification programs may take the form of a shared data platform and jointly developed risk factors. A collaborative clinical program could look at the leading causes of hospital readmissions and weave services and programs around those factors to support patients at greatest risk.

  • Business sustainability: It’s in the interest of health plans to see that their members receive high quality care, recover quickly and fully, and do not return quickly to the hospital. Value-based payments encourage hospitals to share those interests. The agreements should ensure that  financial incentives to hospitals to keep readmissions down are not so punitive that they endanger the hospital’s ongoing operations or its ability to invest in the programs, staff and patient education, and surveillance technology critical to making readmission reduction efforts work.

  • Patient engagement and communication: Insurers or health plans and hospitals are not the only stakeholders, of course. Patients must also take an active role in their care. Helping them to do that requires a collaborative plan itself:

    • Hospital staff and physicians need to clearly communicate what the patient should do upon release in terms of overall self-care, follow up appointments, activity, diet and medication as well when they should contact their physician if symptoms return or they experience side effects.

    • Pharmacists should reconcile discharge medications and the medications patients were on when admitted to reduce the risk of duplicate medications or adverse interactions. They should also talk to the patient about financial issues surrounding filling or refilling their prescriptions.

    • Staff, social workers or health plan representatives also must to assess the needs of the patient’s caregivers to ensure the patient does not return to the hospital simply because they could not receive basic care at home. Can they get the patient to a follow up appointment? Do they understand care instructions? Can they care for the patient or will a referral to another facility be needed before the patient can be sent home? If the caregiver can provide some, but not all, of the care, the health plan or employee assistance plan may need to connect the patient and caregiver with other programs in the community such as visiting nurses, aides or in-home respiratory care services.  

    • The patient needs to engage in his or her own care, too by fully understanding what is expected. Nurses or other staff can ensure they do know what to do by asking them to “teach back” their care information. Pharmacists can do the same to ensure patients know why they are taking each drug, when to take them, and potential side effects. Decisions on the course of treatment should be made jointly with the patient, with every effort to ensure that care decisions reflect the patient’s values and wishes, which increase the likelihood that the patient will adhere to the plan.


  1. Northeast Business Group on Health (NEBGH). Reducing Hospital Readmissions through Stakeholder Collaboration. February 2014.

46 tips for usp 797 success. Download the Sheet.

Learn More About Our Products & Solutions