Readmission management has been a topic of discussion for over a decade, it has only been in the last 2 or 3 years that a deeper understanding of (micro) Social Determinants of Health has given rise to a leading strategy for managing readmission risk and patient experience. The question is how to assess and quantify the risk to invest appropriately to achieve these meaningful outcomes. This presentation will use LifeProfile, which brings 20 years of research across 22 states, over 250 participating entities, 120 major research collaboratives, and 75,000 patients. The research has proven that there are 6 key outcomes necessary for patient success. This session will review the 6 key areas and where the opportunity is to impact them to reduce avoidable admission/readmissions. 

• Define a theoretical framework to manage admission/readmission 

• List the Key Outcomes necessary for a senior to be successful 

• Explain intervention strategies that lead to better outcomes in senior patients in the areas of independence, safety, and burden of care