Data Collection & Analysis
We gather information on readmitted patients — demographics, conditions, locations, contributing factors, and costs — to identify disparities and root causes driving unnecessary returns.
Reducing Avoidable Returns
Hospital Readmission Prevention
BLH uses coordinated care teams and data-driven strategies to prevent avoidable hospital readmissions and support safe, successful transitions back into the community.
Coming home — and staying well — takes a plan.
Our agency has made it our goal to work on strategies that prevent hospital readmissions among diverse populations. By identifying root causes and addressing social risk factors, we help patients get home safely and stay there.
Our Five-Part Strategy
A Proactive, Data-Informed Approach
Multidisciplinary Care Teams
We build coordinated teams that address the full range of patient needs, spanning clinical care, social supports, language access, and health literacy.
Social Risk Factor Support
Housing instability, limited transportation, and lack of primary care access contribute to readmissions. We connect patients to the community supports that address these underlying risks.
Culturally Sensitive Care
We provide communication-focused, culturally responsive care that meets patients where they are — accounting for language preferences, health literacy, and disability status.
Community Organization Coordination
We partner with community-based organizations to extend care beyond the hospital, ensuring a continuous support network during the critical transition period.
Populations We Serve
Equity Across Diverse Communities
Our program serves diverse populations across race, ethnicity, culture, socioeconomic background, language, and health literacy levels. Special focus is given to patients with limited English proficiency, low health literacy, and disabilities.
- Language & Communication
- We track and accommodate both spoken and written language preferences to ensure every patient fully understands their care plan.
- Health Literacy
- Care materials and communications are tailored to each patient's level of health literacy and comprehension.
- Disability Status
- We account for disability status and complexity of medical needs when building transition and follow-up care plans.
- Primary Care Linkage
- We work to connect or reconnect every patient to a primary care provider and usual source of care before discharge.