Readmissions Reduction: What Works?


Author of readmissions reduction article looking at the camera

Matt Allison
Senior Manager, Research and Grants

Time: 10 min



There are not many industries in America that can stand to lose $566 million in a 12-month period. The US hospital industry, however, faces Medicare penalties of $566 million this year for high rates of avoidable hospital readmissions alone. Starting next year, CMS is adjusting their calculations to help rural and safety-net hospitals account for the social determinants of health. This subtle change should help the most at-risk hospitals and account for some of the social issues that go beyond a hospital’s reach, but the focus on avoidable hospital readmissions is here to stay.

Despite increased focus from industry leadership as Medicare penalties take intensify and impact the bottom-line, a meta-analysis of 66 readmission programs found that only 41% of interventions demonstrated statistically significant reductions in readmission rates. This statistic begs the question: what readmissions strategies warrant investment of time and resources?


– 3 Common Strategies with Limited Evidence – 


Graphic depicting the key coordination tactics for working with primary care physicians

01. Heavy Emphasis on Follow-up Visits

A doctor’s visit post-discharge without any context will not improve readmission rates.  One of the most common tactics for readmission reduction is a post discharge outpatient visit with a primary care or specialist provider.  This has been shown in analysis to have limited impact through claims analysis, randomized trials, and CMS trend analysis.  There have been recent studies that show patients who have post-discharge visits have lower rates, but correlation between follow-ups and lower rates does not mean causation.  It seems likely that patients who have enough support and self-resiliency to visit the doctor are also less likely to be readmitted due to the same support and self-resiliency.

The main takeaway is a visit inside of 7 days may have an impact but only for some patients and only if the visit specifically addresses their discharge needs.  If you are not coordinating and communicating closely with community providers then you are wasting valuable resources.

02. Reliance on Patient Interpretation of Discharge Instructions

Discharge plans are required by the Joint Commission on Accreditation of Healthcare Organizations in six categories (activity, diet, weight, follow-up appointments, discharge medications, and worsening symptoms) for heart failure but most facilities provide them to all patients.  However, studies show compliance is poor, instructions are hard to understand, include incomplete data such as meds or labs, and are not delivered by the right person at the right time.  Even the best discharge summary and instructions will leave many patients on an island with limited help.

03. Reliance on proactive contact from patients

Patients who need the most help are less likely to call or ask for help.  This catch-22 prevents the patients who need the most help from actually getting the help they need.  Even with great instructions, education, and ideal staffing you will not maximize impact without systematically contacting patients multiple times in a short period of time.


– 5 Evidence-Based Strategies for Reducing Readmission –


Graphic depicting best practices for readmissions reduction

01. Avoid Singular Interventions

The most important piece of advice for leaders charged with reducing readmissions is that increasing the number of targeted interventions will significantly increase success in readmission reduction.  You can’t rely on only one strategy because the needs of patients are complex. There is no silver bullet that will fix everyone’s issues.

02. Stratify Risk of the Population

Hospital systems with limited resources, especially those being penalized for high readmission rates, struggle to implement multiple interventions due to a cost.  If limiting the number of interventions leads to failure, consider risk-stratifying patients. This should be done at the time of discharge and then selectively apply interventions based on patient needs.  Programs such as Project BOOST have shown impact in readmission and can provide resources to help with risk-stratification.

03. Monitor and Manage Symptoms

Studies have shown that the intervention most associated with reductions in readmission is closely monitoring recent discharges for new symptoms.  This could be home visits, interactive voice response (IVR), or enlisting the help of outside resources such as health coaching.  Preventing major problems through early identification is critical to escalating care and improving health.

04. Improve Patient Self-Management

Systems are more likely to succeed if they educate patients regarding medication needs. Furthermore, it is essential to provide information on how they should start to self-manage their chronic disease.  There are resources available across the country through CMS Quality Improvement Organizations, Area Health Education Centers, and other community resources that can provide training for hospital staff on the principles of patient self-management and help increase the impact of patient education efforts.

05. Understand Your Population

An AHRQ analysis found that Medicare and Medicaid populations are among the most likely to be readmitted, even more than uninsured patients.  It is not just an age issue as readmission rates for non-elderly Medicare patients (under 65) were 25% higher than Medicare patients over 65.  Medicaid patients between the ages of 45-64 were readmitted 60% more often than uninsured patients. Additionally, they were twice as likely to be readmitted when compared to privately insured patients.  Understanding the population that you serve will help set proper expectations and define a path towards success. CMS sends Hospital-Specific Reports to leadership annually and Community Health Needs Assessments are required as part of the Affordable Care Act.  These reports are a great place to start to find out more about your population


– From Knowledge to Action –


Readmissions reduction is a crucial issue facing hospitals right now, and the problem is more acute in rural settings. Given the research on factors that affect readmissions, it is time take action and align your investment to what works. We recommend the following tools for our Health System partners to improve the experience and workflows within the hospital:

Learn more about our 30 day readmissions reduction program


To close the gap of patient experience and navigation beyond clinic doors, we recently partnered with ProxsysRx to develop a 30-day readmissions program. Using its technology-enabled process, Proxsys Rx staff provides patients access to their medications and any related counseling at discharge.

Next, qualifying patients are referred to Pack Health’s digital health coaching and care coordination services. This focuses on educating the patient about their condition and coordinating care to avoid readmission.

To learn more about Pack Health’s digital health coaching program for readmissions reduction, click here.