Hospital readmissions are a heavy burden on both patients and providers. Not only do readmissions increase health care costs for everyone involved, but they are often a sign that there are gaps in care coordination and patient support, which are getting in the way of care delivery and reducing the quality of patient care outcomes.
Below, we’ll explore how to reduce hospital readmissions and how specific high-risk patient readmission strategies can shift providers from a reactive to a proactive mindset, aligning more closely with value-based care models.
Common causes of hospital readmissions
Hospital readmissions within 30 days of discharge are probably one of the hardest challenges faced by providers. Though some readmissions are unfortunately unavoidable, if a health care facility has a high rate of readmissions, it can signify reduced patient quality of life and potential misalignment with data-driven value-based care models. Mitigating readmissions should be a priority for any provider looking to diminish overall costs.
There’s no one singular answer for how to reduce readmission rates in hospitals. Certain conditions tend to fuel readmission rates more than others—for example, septicemia (sepsis) was the number one reason for readmissions according to a 2024 report.
Several other systemic factors can also contribute, including:
- Medication-related issues: Medication errors, along with intolerances and allergies, can lead to unexpected complications and rehospitalization.
- Hospital-level complications: Surgeries and other complex procedures can lead to infections, ulcers, and several other issues that may not be evident when the patient is initially discharged.
- Premature discharges: Discharging a patient too quickly can predispose the patient to another visit sooner than expected.
- Inadequate follow-ups: Patients may not receive appropriate follow-up care, which can range from medication management to physical therapies.
- Social determinants of health: The patient’s own social and economic circumstances can significantly impact the immediate outcome of a hospital visit.
Addressing these multifaceted causes is no easy task, and it often requires a comprehensive approach that encourages hospital- and patient-level interventions.
CMS' Hospital Readmissions Reduction Program (HRRP): Penalties and financial impact
The HRRP is an incentive implemented by the Centers for Medicare & Medicaid Services (CMS) to reduce avoidable readmissions. It involves financial penalties for centers with 30-day readmission rates that go over a set standard. However, it applies only to readmissions for specific conditions such as:
- Acute myocardial infarction (AMI)
- Chronic obstructive pulmonary disease (COPD)
- Heart failure (HF)
- Pneumonia
- Coronary artery bypass graft (CABG) surgery
- Elective primary total hip arthroplasty and/or total knee arthroplasty (THA/TKA)
The result of the financial penalties can go up to a 3 percent reduction in Medicare and Medicaid payments. This creates a strong pressure for leaders to get a handle on hospital readmission rates as soon as possible—not just to enhance patient care but also to maintain financial viability.
Proven strategies: How to reduce hospital readmissions
Reducing hospital readmissions involves a holistic strategy that includes clinical interventions and patient-level factors. Although the core approaches and the results will vary from provider to provider, here are some crucial improvement areas to keep in mind:
Strengthen discharge planning
Comprehensive discharge planning is crucial to ensure the patient has a smooth journey once they leave the hospital. Individuals should thoroughly understand their care instructions and have the necessary resources at hand. Patient education and scheduling follow-up appointments are a top priority in all cases.
Medication reconciliation and management
Medication adherence errors and discrepancies can come from either the patient or the clinician. When providers take the time to ensure patients fully understand their medication regimen, this can significantly reduce the incidence of last-minute surprises and unexpected hospital visits.
Enhance post-discharge follow-up
Post-discharge follow-ups play an essential role in addressing complications early, sometimes even before they become apparent. Designing programs that keep a close eye on the patient during the first days after discharge can help providers deal with high readmission rates.
Improve care transitions
Care transitions require all medical staff involved in a patient's care, whether they all work at one facility or are spread across multiple health care centers, to be highly coordinated and willing to share a care vision for a specific patient. These interventions should be closely monitored to avoid patient data slipping through the cracks.
Address social and behavioral factors
Social and economic determinants such as transportation issues, food insecurity, housing instability, and unemployment can significantly impact a patient’s ability to follow post-discharge care plans. At the same time, they can directly influence the health and well-being of individuals despite their initial condition.
Providing or making support services easily accessible will result in measurable improvements in patient outcomes. Naturally, this is even more important in underserved and misrepresented populations.
Behavioral science: The missing link in reducing readmissions
Traditional clinical models and interventions often fall short when it comes to addressing the behavioral aspects of health care. Understanding patient behavior is paramount to bridging the gap between reactive and proactive care, while also providing patients with more realistic care plans that actually work.
Behavioral health introduces concepts such as habit loops, which identify cues, routines, and rewards as components of everyday behaviors. Modifying each of these steps fosters positive health behaviors that don’t feel stressful for the patient. This can be achieved through subtle prompts or cues known as “nudges,” which guide patients without restricting choices.
Behavioral health offers a way to positively reinforce specific behaviors that ultimately improve patient follow-through.
Implementation roadmap: How health plans & providers can succeed
Implementing a successful hospital readmission rates strategy requires sustained, daily change.
Wellth applies behavioral economics to encourage daily health actions among patients. We firmly believe that structured rewards and daily patient engagement are the road to better health outcomes—and our results confirm this. Our platform has been able to reduce 90-day readmissions by 45 percent for post-discharge patients with post-acute coronary syndrome (ACS). We have also achieved over 89 percent average daily adherence, showing that patients feel comfortable with the platform and the actions suggested. Where Wellth really shines is in high-risk populations. For example, using Wellth has resulted in a reduction of 1.29 in HbA1c in a poorly controlled type 2 diabetes population
To learn more about how Wellth can support your care center’s goals, check out our solutions today.