Hospitals across the country are experimenting with solutions that are reducing their 30-day, all-cause readmission rates. Here are five strategies that every hospital should have in its playbook against avoidable readmissions and the financial penalties that come with them.

Discharge Planning

When patients are discharged from the hospital, they typically are not in the best frame of mind to remember or follow detailed discharge instructions. The instructions can cover a number of complex aspects of post-discharge care, including medications, prescriptions, nutrition, hygiene, wound care, therapy, exercise, durable medical equipment, medical devices, vital signs, warning signs, follow-up visits to the doctor and more.

Recognizing that not following just one of the many instructions can result in an avoidable readmission, hospitals are improving the discharge planning process. Specifically, they are coming up with innovative ways to educate patients on what it takes not come back too soon. Some are requiring patients to read back the instructions. Others are videotaping the discharge process and giving patients online access to the video to review as many times as needed. Some are doing audio recordings of the discharge process for the same purpose. Many have started “meds to beds” programs in which prescriptions are filled at the bedside before patients leave rather than relying on discharged patients to get their prescriptions filled on their own. 


Lack of medication adherence by patients after they leave the hospital is . Not taking prescribed medications or not taking them properly can lead to an adverse health event and a trip to the emergency room. E-prescribing by providers can mitigate that risk.

  • The provider sends the prescription electronically to the patient's pharmacy, eliminating the chance that the patient loses the written prescription or doesn't bring it to the pharmacy.
  • The pharmacy can check the prescription against others in the patient's current medication history for contraindications that could create a new medical problem.
  • The pharmacy knows that a prescription has been written for the patient and knows if the patient hasn't picked it up. The pharmacy can remind the patient to pick up the prescription through a number of methods, including phone calls, automated calls, e-mail and text messages.
  • The e-prescribing-triggered visit to the pharmacy creates an opportunity for the pharmacist to discuss the prescription with the patient and answer any questions he or she has about why taking the medication is important to avoiding another inpatient stay.
  • The pharmacy can synch up the new prescription with others the patient may be receiving so they all can be refilled at the same time. Medication synchronization has been shown to improve patients' medication adherence.

Tony Willoughby, chief pharmacist, Health Mart

Post-Discharge Follow Up

With hospitals assuming the clinical and financial risk for patients for 30 days after discharge, they must extend their care management plans into patients' homes. Hospitals should develop standardized 30-day post-discharge care management plans that can be tailored for each patient. By using predictive modeling, hospitals can identify patients at most risk for readmission and customize the plans accordingly.

A key component of standardized discharge care management plans is scheduling patients' follow-up appointments with doctors before they leave the hospital. Like filling prescriptions, hospitals can't leave that important follow-up visit to chance. Follow-up appointments should be done within the first week to catch any medical problems before they require acute-care services. Hospitals should do everything they can to ensure discharged patients keep that first follow-up appointment, including reviewing patients' insurance benefits for appointments and arranging transportation to and from appointments.

Standardized discharge care management plans also should connect all the caregivers and all the sites involved in the provision of post-discharge care to patients. Ideally done electronically, caregivers and sites can alert each other to changes in patients' medical conditions or treatment regimens that may warrant early intervention.


A standardized discharge care management plan is crucial to reducing avoidable and costly hospital readmissions. To optimize the effectiveness of those plans, they should include a telehealth, or remote health monitoring, component. This process can be as simple as patients taking their own vital signs and reporting the results back to case managers on a regular basis either by phone or by e-mail.

The process can be more advanced with those same vital signs and more being taken by remote medical monitoring devices that record the data and feed the results into patients' EHRs, which can be accessed by case managers or other caregivers. Another step up on the technology ladder is telemedicine, in which physicians or nurses review the results and then conduct virtual visits with patients online via computer.

Regardless of the technology level, the goal is the same: To identify any changes in patients' health status that can be addressed immediately as they occur. Such early intervention can resolve a medical issue before it becomes acute.

Summerpal Kahlon, M.D., vice president of business development, RelayHealth Pharmacy Solutions

Patient Contact Centers

An often-overlooked opportunity to prevent avoidable hospital readmissions is the traditional customer or patient call center operated by a provider, payer or supplier. Patients start a new medical journey after discharge, and it's a journey they hope does not lead back to the hospital. At the start of that journey, they may have questions about their treatment plans, coverage options or prescribed medications. For answers, many patients dial up customer or patient call centers.

That call creates an opportunity to engage patients well beyond answering simple questions about when they can exercise, what their co-pays or deductibles are or whether there's a generic alternative. The call is a chance to engage patients in behavioral support that, if done effectively by well-trained call center staff, can improve the patients' health status and reduce the risk of returning to the hospital.

By re-inventing their call centers as “patient centers,” providers, payers and suppliers now are in a position to remove barriers to getting patients the exercise they need or the medication they need or the financial support they need to succeed on their new medical journey to better health.

Jennifer Richard, director of call center operations, Studiomaca

Hospitals that have used the five strategies are reducing their 30-day, all-cause hospital readmission rates with the result being better health for patients and better business health for themselves.


About the author

Studiomaca editorial staff is committed to sharing innovative approaches and insights so our customers can get the most out of their business solutions and identify areas for operational improvement and revenue growth.

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