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Reducing Readmissions Preparation Program Criteria

Medical Team Medical Worker


Your journey is set up in three phases. Participating nursing homes will progress through the levels over the nine-month period, January 1–September 30, 2018. These steps will help you be prepared for the Centers for Medicare & Medicaid Services (CMS) Skilled Nursing Facility Value-Based Purchasing (SNF-VBP) readmission reduction program, which goes into effect October 1, 2018, and develop your prevention program. Work with your Reducing Readmissions Committee to focus on these prevention steps. Contact HSAG as you complete each phase:

You may also download a print copy of the Program Criteria.

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Phase 1 "Starting the Journey" (January–February)

  1. Submit signed commitment agreement to participate. Sign up online or download the Agreement PDF and fax it back.
  2. Develop and submit your Reducing Readmissions Committee Roster.Complete a Readmission Committee Roster and fax it back.
  3. Complete Quality Assurance and Performance Improvement (QAPI) Self-Assessment Survey for period October 2016–September 2018. (Check with HSAG to confirm if already submitted:
  4. Request and review all available CMS readmissions data:
    • HSAG Nursing Home Readmissions Report (baseline period: Q3 2016–Q2 2017, 7/1/16–6/30/17). To request your report, email
    • Quarterly CASPER Confidential Feedback Report, which includes your CMS readmission rate. For information on how to access your CASPER report, see CASPER Report Instructions.
    • Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNF-RM) Baseline and Performance Period Rates. To access data, go to Medicare’s Nursing Home Compare website, under the Spotlight section at:
  5. Complete Nursing Home Readmission Pre-Assessment
  6. Begin implementation of a readmission intervention using the QAPI Performance Improvement Project (PIP) Charter for reducing readmissions.Download QAPI PIP Charter.

Phase 2 "Well on the Way" (March–April)

  1. Meet Phase 1 level criteria.
  2. Participate in at least two learning opportunities.2 Consider including your Readmission Committee and/or Inter-Disciplinary Team (IDT) members.
  3. Track and trend, daily, your Medicare Fee-for-Service 30-day readmissions data either through electronic health record or a readmissions dashboard.
  4. Routinely discuss past 24 hours readmissions during morning huddle. For useful tools, see SNF Transfer Checklist and SNF Pre-Admission Huddle Equipment Checklist.
  5. Review readmission trends weekly with executive leadership (administrator, director of nursing, or medical director).
  6. Conduct monthly chart reviews for some Medicare Fee-for-Service patients readmitted in the past 30 days.
  7. Conduct Plan-Do-Study-Act (PDSA) cycle(s) on readmission intervention(s) using the QAPI PIP process for reducing readmissions. Download a QAPI PDSA Cycle.

Phase 3 "Leading the Way" (May–September)

  1. Meet Phase 2 level criteria.
  2. Participate in an additional three learning opportunities,2 for a total of five by the end of the program.
  3. Complete Nursing Home Readmission Assessment (post). (PDF download coming soon).
  4. Achieve a 6 percent relative improvement rate (RIR)3 from baseline period Q3 2016–Q2 2017 (7/1/16–6/30/17) to remeasurement period Q4 2017–Q3 2018 (10/1/17–9/30/18).
  5. Continue your PIP readmission intervention by using data monitoring and reporting results through your QAPI committee.
  6. Submit a story board of your readmission program’s successes and lessons learned. Select submissions will be shared during the final webinar session.


1. A readmission intervention will include conducting some chart reviews for Medicare Fee-for-Service patients who readmitted to have a baseline understanding of your gaps.

2. Learning opportunities include: HSAG 2018 webinar sessions and in-person trainings, attendance at a readmission-related session of the California Association of Health Facilities (CAHF) Summer Conference and Quality Symposium, site visits, or coaching calls.

3. RIR measures the relative change in the readmission rate from baseline. A positive value indicates performance that has improved from baseline, while a negative value indicates performance that has not shown improvement from baseline. The formula for RIR is (Baseline-Current)/Baseline. For example, if your baseline readmission rate was 19.6% and your current readmission rate is 18.4%, you have achieved a 6.1% RIR (19.6%-18.4%/19.6% = 6.1%).