Recording Available: Addressing Unnecessary Hospital Readmissions Through Person-Centered Chronic Disease Care

The recording is now available for the Masterclass Session “Addressing Unnecessary Hospital Readmissions Through Person-Centered Chronic Disease Care.”

Avoidable hospital readmissions remain a persistent challenge for older adults living with chronic conditions such as stroke, diabetes, COPD, and heart failure. 

This Masterclass Session explores how person-centered, in-home chronic disease management can significantly reduce readmission risk by addressing clinical, functional, and psychosocial drivers of decline. 

Audiences will review proven tools, such as INTERACT, evidence-based care transition practices, and ComForCare’s Reducing Hospital Readmissions Program, to strengthen continuity of care, improve early risk identification, and support safer recoveries at home.

Session Objectives:

• Identify common clinical and non-clinical drivers of avoidable hospital readmissions among older adults with chronic disease.
• Apply person-centered strategies to support disease self-management and early symptom recognition.
• Describe how tools such as INTERACT enhance communication and escalation across care settings.
• Explain how in-home care programs can support care transitions and reduce rehospitalization risk.

Panelists:

Tune In: 

Download Masterclass Session Materials

• Presentation
• Session Handout

Helpful Resources:

• The Centers for Medicare and Medicaid Services (CMS) HHRP (Hospital Readmission Reduction Program
• Hospital Readmissions Reduction Program
• CMS – Skilled Nursing Facility Value Based Purchasing Program
• CMS SNFVBP Confidential Feedback Reports
• CMS SNF VBP Frequently Asked Questions
• Skilled Nursing Facility Within-Stay Potentially Preventable Readmission (SNF WS PPR) Measure for the Skilled Nursing Facility Value-Based Purchasing (SNF VBP) Program
• AHRQ Hospital Guide to Reducing Medicaid Readmissions
• Quality Improvement Organizations
• The risks of hospital stays: A guide to safe recovery and returning home for older adults (Mayo Clinic) 
• Pneumonia – Symptoms and causes (Mayo Clinic)
• Reducing Hospital Readmissions (ComForCare)