VHAN Key Aim

Transitions of Care

Our vision is to reduce preventable readmissions by creating collaborative transitions of care processes to increase team-based support for at-risk and high-risk patients post-discharge.

What VHAN Is Doing

Three-phase Interaction Action Plan

VHAN created an action plan to reduce the readmissions rate by 2% and improve transitions of care. Using patient-level data analysis, the plan identifies readmissions trends and opportunities to refocus or implement new interventions. It also places an enhanced focus on medication management, improved patient follow-up, and coordination of care across settings and providers. Data-driven approaches are targeted at improving workflows, exploring home-based care models, and increasing advanced care planning and palliative care initiatives.

Identification of Readmission Trends and High ED Utilization

Using 2019 as baseline, we found that readmission rates at seven large VHAN practices were higher than VHAN’s median readmission rate. Clinical Quality Transformation Advisors completed a transitions of care assessment with each practice, and then shared engagement strategies for preventing readmissions.

Those strategies included:

Developing Action Plans

to identify patients and reasons for readmission 

Leveraging Best Practices

to help improve rates at lower-performing practices 

Sharing Information

on readmission rates and clinical categories for readmissions

Publishing Monthly ED Reports

to help pinpoint outreach for education and care management opportunities 


All focus practices had a decrease in readmission rates for their Medicare population, and
three focus practices had a decrease in their readmission rates for the commercial population.

The True Value

Robert is 77 years old and was recently hospitalized due to shortness of breath and lower extremity edema.
He has a history of high blood pressure and high cholesterol.

After Robert was discharged from the hospital, a VHAN RN followed up and
learned that Robert needed extra support.


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