A readmission is a return hospitalization after discharge and most often measured within 30 days of initial hospital stay. Patients in transition - those moving from one care setting to another - are at increased risk for hospital readmission. Unanswered questions including the following, can increase patient risk for readmission: who is in charge of the patient transition, what is the plan - to include medication reconciliation, whether the plan and follow-up instructions are understood, and knowledge of whom to call with questions once they are home or in their new care setting. WHAT ARE WE DOING TO ADDRESS THIS? i.e., partnering with stakeholder groups … (PER MC EDITS)

Goal: By September 27, 2018, a 12 percent reduction in 30-day readmissions as a population-based measure (readmissions per 1,000 people)