, Volume 29, Issue 5, pp 798-804,
Open Access This content is freely available online to anyone, anywhere at any time.
Date: 01 Apr 2014

Implementation Science Workshop: Primary Care-Based Multidisciplinary Readmission Prevention Program

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Editor's note: In this installment of Implementation Science Workshop, Dr. Cavanaugh and colleagues describe implementation and evaluation of a readmission prevention program at the University of North Carolina. In an accompanying commentary, Elizabeth Yano of the West Los Angeles VA highlights strengths and weaknesses of their approach, emphasizing generalizable lessons for learning health care organizations. -- Lindsay Jubelt, MD, MS, Contributing Editor


Approximately 20 % of Medicare beneficiaries discharged from the hospital are readmitted within 30 days, costing approximately $17.4 billion annually.1 Because many of those readmissions are preventable, patients, payers, and providers have prioritized improvement in discharge and care transitions. Several multifactorial approaches have been successful in reducing hospital readmissions but have not focused on how primary care practices contribute to the transitional care process.28

Systematic reviews have not clarified whi ...