Include all diagnoses, payers in readmission projects.

As the Centers for Medicare & Medicaid Services begins to penalize hospitals for excess readmissions and state Medicaid agencies and commercial payers are likely to follow suit, case managers should assess all patients for risk of readmission regardless of diagnosis or payer. Experts recommend that you: Consider home health services even if it's just one visit for medication reconciliation. Make sure patients receive the services they need in the community to follow their discharge plan and stay out of the hospital. Take the patient's family dynamics and living conditions into account when developing a discharge plan. Identify and engage the patient's caregivers early in the hospital stay and get them involved in the discharge plan.