The majority of readmissions and emergency department visits within 30 days of hospital discharge are considered preventable. Contributing factors to readmissions include complex health care needs of patients, premature hospital
discharge, and inadequate discharge preparation during hospitalization. In response to the financial reimbursement penalties imposed on hospitals for readmissions within 30 days of discharge, several strategies have been implemented in hospitals across the nation. Some of these strategies have focused on improving care coordination and improving readmission risk assessment. While each strategy has demonstrated some success, there is opportunity to bundle strategies to improve the discharge preparation process by standardizing pre-discharge readiness for discharge assessment and
improve communication within the healthcare team. We are proposing a four-campus study.