Role clarity and organizational capacity as prerequisites for reducing readmissions: Comparing high- and low-performing VA facilities.

BACKGROUND: Older adults face a high risk of unplanned hospital readmissions during transitions from hospital to home. Despite system-wide initiatives, substantial variation persists across Veterans Health Administration (VHA) facilities. OBJECTIVE: To identify organizational factors and transitional care processes associated with high and low readmission rates. METHODS: We conducted a qualitatively driven explanatory sequential study of 10 VA medical centers selected based on 30-day risk-adjusted readmission rates. Ten facilities (five high-performing, five low-performing) were purposively sampled for qualitative investigation. Semi-structured interviews with clinicians explored discharge planning, communication, and follow-up care. Data were analyzed using rapid qualitative analysis and thematic matrices. RESULTS: Based on interviews with 54 clinicians, we found that high-performing facilities consistently implemented pharmacist-led medication reconciliation, ensured patients received medications prior to discharge, scheduled follow-up appointments before discharge, and engaged leadership in monitoring readmission metrics. These processes were enabled by organizational conditions such as clear role delineation, effective communication systems, and adequate staffing capacity. Low-performing facilities faced compounding barriers, including unclear accountability, fragmented communication, and capacity constraints that undermined execution despite similar policies. CONCLUSIONS: Reducing readmissions needs more than clinical protocols; organizational readiness is critical. Investments in team structure, communication protocols, and capacity may yield greater and more sustainable improvements than adding new programs.