ArticlesReducing Hospital Readmissions in Upstate New York Teasing Out the Effective ProgramsSummers, Michele L. PhD, RN-BC, FNP-C; Atav, Serdar PhDAuthor Information Michele L. Summers, PhD, RN-BC, FNP-C, is Clinical Assistant Professor with the Decker School of Nursing at Binghamton University. She teaches in the undergraduate nursing and graduate nurse practitioner programs. Her interests include the house call as a care delivery model and the phenomenon of community stigma. Serdar Atav, PhD, is Professor of Health Policy and Research at Binghamton University. He teaches doctorate and master's level courses in health policy, research methods, and applied statistics. He is actively involved in collaborative research work that has led to numerous publications. His current research is opioid prescriptions in emergency departments. Address correspondence to Michele L. Summers, PhD, RN-BC, FNP-C, Decker School of Nursing, Binghamton University, 4400 Vestal Pkwy East, Binghamton, NY 13902 ([email protected]). The authors report no conflicts of interest. Professional Case Management: January/February 2020 - Volume 25 - Issue 1 - p 26-36 doi: 10.1097/NCM.0000000000000371 Buy Metrics Abstract Purpose of Study: The study's purpose was to identify hospital programs, organizational characteristics, and levels of nursing involvement in hospital programs that contribute significantly to reductions in readmission rates and reimbursement penalties for hospital systems in upstate New York. Primary Practice Setting: Hospitals located in upstate New York. Methodology and Sample: No sampling technique was employed because the cohort included hospitals located in upstate New York. Hospitals in upstate New York were selected (N = 94), representing 53 counties ranging between metropolitan and rural status. Using an ex post facto design within the framework of the ecological and synergy models, organizational characteristics of hospital systems and educational levels of nursing involvement in hospital programs were analyzed and coded. Independent-samples t tests, analysis of variance, and Pearson correlation tests were conducted. Results: Organizational programs that reduce various hospital readmission rates and reimbursement penalties for hospitals in upstate New York are (1) certified home health agencies; (2) telehealth; (3) house calls; (4) advanced practice nurses on care management interdisciplinary discharge teams; and (4) increasing the number of hospital readmission reduction programs (HRRPs) utilized. Implications for Case Management Practice: Hospitals should: Encourage and provide support for their case management departments to increase utilization of certified home health agencies, telehealth, and house calls, which contribute to reductions in readmission rates and decreased reimbursement penalties. Incorporate advanced practice nurses into case management teams for improvement in the excess readmission ratio for pneumonia. Continue to support government and hospital policies that increase resources for evidence-based HRRP initiatives and that improve Medicare reimbursement formulas. © 2020 Wolters Kluwer Health, Inc. All rights reserved.