Aims and Objectives: To identify structure, process, and outcomes associated with the implementation of transitional community-based management of hospital readmission rates.

Background: Population health-based projects have previously been described (Chapters 10 and 13). Using a transitional community-based readmissions plan for patients with heart failure, categorize quality metrics into structure, process, and outcomes.

Questions/comments to be considered are as follows:

1. What are your data input, output, and measures of success?

Suggested response: The data input would be community health workers and patients with heart failure, the output would be readmission plans, and the measure of success would be surveying patient responses.

 2, Explain how your devised model incorporates social context.

• The community-based management program will ensure that social contexts such as social or familial support, income, or cultural norms are incorporated.
• Patients will be treated within their social context and communities.

 3.How will you assess your population or community?

Suggested response: The patient assessment instrument in Centers for Medicare & Medicaid Services (CMS) measure management programs can be used to assess the population or community.