Table 3.

Major Themes and Core Strategies

Major Theme	Core Strategies	Participant Response Rate
Population health	Coordination across the care continuum	60%
	Patient education	73%
	Developing local and community approaches to healthcare	73%
Hospital operations and patient interactions	Multidisciplinary rounding teams	40%
	Post-acute services	40%
	Monitoring of readmission rates	87%
Leadership and mission	Setting the mission and vision	67%
	Enabling team members and reducing barriers	67%
Barrier to reducing readmissions	Social factors	80%
	Patient compliance	40%
	Access to care	40%