Overview of the Environmental Scan of Primary Care-Based Effort To Reduce Readmissions

Research from the AHRQ’s Healthcare Cost and Utilization Project (HCUP) indicates high rates of readmissions in the Medicare population and among the adult, non-obstetric Medicaid population. Many efforts to reduce readmissions have focused on the hospital setting and staff using evidence-based programs, such as AHRQ’s RED (Re-Engineered Discharge) toolkit for hospitals and The Hospital Guide to Reducing Medicaid Readmissions. The evidence-base for the primary care setting to reduce readmissions and improve patient safety is comparatively lacking. This gap in the literature is becoming more pronounced as primary care is increasingly called upon to serve as the key integrator across the healthcare system.

In 2015, AHRQ funded a contract focused on understanding the primary care-based transitional care workflow through the Accelerating Change and Transformation in Organizations and Networks III (ACTION III) mechanism. This contract directly addressed the Agency’s goal to conduct research to enhance the quality of healthcare and focused on a current major policy issue of national significance, as avoidable readmissions are a major indicator of poor quality and patient safety. Building on the previous investments by the Agency on research on inpatient settings, the contract contributes to the evidence base on preventing readmissions by in the primary care setting.

The primary goals of the research were to:

  1. Analyze current processes in the primary care visit associated with hospital discharge.
  2. Identify components of a re-engineered visit to reduce readmissions from the primary care perspective.

The information identified as a result from AHRQ’s investment provide insights on the components and themes that should inform the development of effective interventions that can be tested in a diverse set of primary care clinics. The environmental scan examines what is currently known about reducing readmissions from the primary care perspective, with a focus on evidence of successful practices, by analyzing the findings of 42 peer-reviewed articles and 30 items from the gray literature.

The environmental scan is the first product resulting from the contract.

For additional information, please contact Eileen M. Hogan, M.P.A., Public Health Analyst, AHRQ, either at Eileen.hogan@ahrq.hhs.gov or 301-427-1307.

The environmental scan was funded under AHRQ/HHS contract number HHSP233201500019I/HHSP23337002T. The findings and conclusions in this document are those of the authors, who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this document should be construed as an official position of AHRQ or HHS.


Project Team & Development Partners

The project team was led by John Snow, Inc. (JSI). The partners for this work included Altamed Health Services, Cambridge Health Alliance, Kaiser Permanente Colorado, and the University of Southern California Gehr Family Center for Health Systems Science.

Page last reviewed March 2019
Page originally created March 2019
Internet Citation: Overview of the Environmental Scan of Primary Care-Based Effort To Reduce Readmissions. Content last reviewed March 2019. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/patient-safety/settings/ambulatory/reduce-readmissions.html
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