DY4 Readmissions Learning Collaborative

RHP 6 Readmissions Learning Collaborative

The RHP 6 Learning Collaborative (LC) to reduce hospital readmissions is underway in our region. This LC is developed and led by a committed cross-functional team of professionals, representing hospitals, mental health centers, public health, the University of Texas Health Science Center at San Antonio, Medicaid health plans, and community organizations. Check out our commitment poster from our November event!

15 teams have signed up to participate. All are working to reduce readmissions by 5% in DY4.

For more details about this opportunity to improve health and transform care, please read the Learning Collaborative Charter.



Past Events:

An introductory webinar was held on October 9th. Steering committee members provided an overview of the LC and expectations for participation.

View webinar recording

View webinar slides 

RHP6 Readmissions Learning Collaborative Learning Session #1

November 13, 2014
10:00 AM – 3:00 PM
Clarity Child Guidance Center
8535 Tom Slick
San Antonio, TX 78229

Sign in Sheet


 A demonstration webinar showing how to use Performance Logic to track results was held on December 10th.

View webinar recording   *     View webinar slides

Monthly webinar #1 was held on December 11th with guest speaker Dr. Amanda Mixon from Vanderbilt University Hospital.

View webinar recording   *  View webinar slides (Huber)   *   View webinar slides (Mixon)

Article: Risk Prediction Models for Hospital Readmission: A Systematic Review

Study Protocol

Monthly webinar #2 was held on January 8th with guest speaker Dr. Amy Boutwell from Collaborative Healthcare Strategies.

View webinar recording  *  View webinar slides

Link to CMS Conditions of Participation

Article: Factors contributing to all-cause 30-day readmissions: a structured case series across 18 hospitals

RHP6 Readmissions Learning Collaborative Learning Session #2

February 12; 9AM – 4 PM

La Quinta Suites & Conference Center

4431 Horizon Hill, San Antonio, TX 78230


Sign In Sheet

Poster Template - complete one per team. Directions on slide 1

Presentation: Welcome and LC Update

Presentation: Using mHealth tp Reduce Readmissions for Diabetics

Team Presentations: Medina Regional Hospital, Peterson Regional Medical Center, University Health System

Presentation: UTMB’s Experience in Reducing Readmissions through the RHP2 Learning Collaborative

Presentation: Working with Community Partners to Reduce Readmissions

Monthly Webinar #3 - March 19, 12:00 PM – 1:00 PM Guest Presenters: LaTosha Selexman and Deborah Moore from the Harris County Area Agency on Aging discussed how they use the Eric Coleman Care Transitions Model to reduce readmissions in five Houston hospitals.

Monthly Webinar #4 – April 9, 11:00 AM - 12:00 PM - Guest Presenter: Dr. John Ovretveit, Director of Improvement, Implementation and Evaluation, Medical Management Centre, The Karolinska Institutet, Stockholm Sweden. Dr. Ovretveit discussed implementation of best practices, what is really necessary to achieve an outcome, and how there is variability in implementation depending on various factors.

This event was co-sponsored by the Improvement Science Research Network.


RHP 6 Readmissions LC – Check-in webinar - May 21, 2015 12:00 PM CDT

We discussed current status of projects and next steps for the LC, including the summary report.


Webinar Co-Hosted with our friends at the Improvement Science Research Network (ISRN):

Controlling Avoidable Readmissions Effectively (Project C.A.R.E.) The first in the Wrestling Readmissions series was held on June 10, 2015 at noon, as Gulshan Sharma, MD, MPH, FCCP offered insights into key interventions known to reduce readmission rates and shares early lessons from readmission programs.

Dr. Sharma’s presentation focused on these key points:

  • Familiarization with key interventions that have shown to reduce readmission rates.
  • Understanding elements of project BOOST and its implementation using Health IT.
  • Examining early lessons learned on readmission project under DSRIP 1115 Waiver in Region 2 of the state of Texas.


RHP6 Readmissions Learning Collaborative Learning Session #3 took place during the RHP 6 Learning Collaborative Summit on July 20, 2015.


For more details about this opportunity to improve health and transform care, please read the Learning Collaborative Charter and Pre-Work. If you have further questions, contact:
Carol A. Huber

DY4 Primary Care Learning Collaborative

The RHP 6 Primary Care Learning Collaborative: A DSRIP Road Trip!

This was a road trip like no other! We visited colleagues and learned from DSRIP projects in action! All events included opportunities for networking and collaboration. Click to discover the full DY4 DSRIP Road Trip itinerary. It was a transformative experience.

Completed Events:

First Stop – Uvalde Memorial Hospital


Second stop – School-Based Healthcare

Participants enjoyed a day learning about school-based health! Dr. Julie Novak shared the nurse-managed clinic model implemented at various Avance Head Start programs. San Antonio Metropolitan Health District’s dental team discussed the importance of school partnerships to improve children’s oral health. The University Health System team gave us a tour of the school-based mobile clinic that has helped achieve a 100% immunization rate in Harlandale ISD. There was even time for music, PE and recess!

February 6; 10AM – 2 PM

Avance at Fenley Elementary, San Antonio, TX

934 Flanders


Third Stop: Integrating Physical and Behavioral Health Care

Hosted by the Center for Health Care Services at the Haven for Hope

Friday, April 10, 2015: 9:00 AM – 3:00 PM


Sign in Sheet



Fourth Stop – Guadalupe Regional Medical Center

The DSRIP Road Trip to Guadalupe Regional Medical Center (GRMC) featured the Guadalupe Clinic for Chronic Disease Care and more! In addition to this project, participants learned how it links with three other projects at GRMC, including Transitional Care, ER Navigation and Palliative LIFE Care.  These projects hinge on one another for the benefit of the patient ensuring they receive the necessary resources from the most appropriate care provider with top notch education to ensure the highest possible patient outcomes and reducing unnecessary hospital readmissions. GRMC also shared how it has developed a collaborative team approach with key leaders from each of the projects and ancillary staff that has proven to reduce unnecessary hospital readmissions.

July 9th from 10 AM – 2 PM in Seguin, Texas.


Sign In Sheet


Release: 2014 Community Health Improvement Plan

On July 23, 2014, the Health Collaborative released its 2014 Community Health Improvement Plan. RHP6 DSRIP providers were invited to attend to identify opportunities for collaborative partnerships and shared aims.

This Community Health Improvement Plan is the result of a formal community health improvement assessment and planning effort that reflects over 24 months of collaborative work with agency partners and community stakeholders, to establish a shared vision, conduct a comprehensive community health assessment, and develop  an assets-based planning document. We are thankful for the support and valuable input of stakeholders and partners from across multiple sectors that took part in the community workgroups.