Hospital readmissions can have a significant negative impact on health systems from both a clinical and financial perspective.

Readmissions are one of the most expensive scenarios to treat, as the Agency for Healthcare Research and Quality (AHRQ) reported that hospital costs can reach $14.3 billion for patients readmitted to the hospital within 30-days following discharge.

Hospital readmissions can also result in healthcare providers losing some of their federal payments since the Centers for Medicare and Medicaid Services (CMS) began penalizing hospitals for 30-day readmissions in 2012. In 2017, for example, over 2,500 hospitals paid more than $564 million in penalties for excessive 30-day readmission rates.

In addition to being costly, preventable readmission rates are also an indicator of patient outcomes. In fact, according to the Medicare Payment Advisory Commission (MedPAC), hospitals who have experienced a decline in readmission rates since the launch of the Hospital Readmissions Reduction Program (HRRP) also experienced a reduction in mortality rates across patients with heart failure, pneumonia, and acute myocardial infarction.

While hospital readmissions have declined by 8% from 2010 to 2015, payers across the healthcare industry are including hospital readmission rates as a quality measure in value-based reimbursement programs. That means hospitals are more likely to continue facing costly penalties if hospital readmission rates linger.

In order to reduce hospital readmission rates and avoid penalties, health systems and providers are recognizing the importance of engagement and communication with their patients following discharge. During the 30-day window following discharge, patients need better communication about their care instructions in order to proactively address issues as they arise—and before they escalate.

Timely and consistent patient outreach is critical to these communication efforts. Here are four tips to help hospitals and providers reduce readmissions using automated technology.

1. Ensure Smooth Transitional Care

Communication breakdowns are often to blame for hospital readmissions as ineffective care transitions from the hospital to a post-acute or home care setting. To avoid this, it’s important to identify a primary person who is solely held accountable for coordinating care after discharge.

Automated technology can help to enable this, helping patients manage their medications and schedule follow-up care through text message reminders. Self-monitoring technology that syncs with medical records can also help patients manage their care once they’re at home. And having a single point of contact to review this data as it’s synced can ensure care teams are able to recognize and respond to signs of a worsening condition before it’s too late.

2. Identify Which Patient Populations Are at Greatest Risk

Advanced software and technology can help hospitals and health systems identify at-risk patients early so that they can focus their attention on proactively caring for and communicating with those populations. Using risk stratification and data analysis, technology can help to pinpoint which patients are more likely to wind up back in the hospital.

With seamless EMR integration, automated technology can sift through your health system’s medical records using an algorithm to identify patients who are at a greater risk for hospital readmissions.

Medicaid and uninsured patients are often at an increased risk of avoidable hospital readmissions, according to research from the Healthcare Cost and Utilization Project (HCUP). In fact, non-maternal Medicaid patients between the ages of 45-64 were readmitted 60% more often than uninsured patients and twice as often as privately insured patients.

3.  Address the Root Cause of Hospital Readmissions for your Patient Population

Taking a deeper look at the root cause of hospital readmissions for your particular patient population is crucial as well. For example, are there social determinants of health that are impacting your patients’ risk for hospital readmissions?

Social determinants of health are the conditions by which people live, work, and play, according to the American Academy of Family Physicians. These environmental factors outside of the doctor’s office all play a significant role in an individual’s health and wellness, regardless of age, gender, ethnicity or race.

In fact, up to 55% of health outcomes are impacted by elements outside of the control of the doctor’s office, including:

  • Socioeconomic status
  • Education
  • Physical environments
  • Employment
  • Social support networks
  • And more

Screening for challenges such as housing instability, food insecurity or transportation barriers can help you proactively provide support services that make keep your patients out of the hospital after discharge.

4. Reinforce Discharge Care Instructions

Finally, reinforcing discharge care instructions to patients and their caregivers can help to make the care transition from discharge to home more effective. Whether it’s due to a misunderstanding of the medical condition or insufficient information on how to care for it, inadequate communication can be to blame.

Educating patients about their follow-up care can help reduce hospital readmissions, and should include both written post-discharge instructions and ongoing communication to help them monitor their condition at home.

Patients should know exactly what to look for and what to do when they leave the hospital. Automated text messaging solutions can help health systems implement educational communication at scale, delivering customized messages to patients based on their unique conditions and care plans. Reminding patients of post-discharge instructions at regular intervals can help patients to stay on top of their recovery.

Hospital readmissions can be costly, both to health systems’ bottom lines and the wellbeing of patients. To help reduce the number of patients who return to the hospital after discharge, hospitals and providers can leverage automated technology to better engage their patients with ongoing communication before a patient returns to the emergency room.


To learn more about how automated technology can help your health system scale patient communication and improve quality outcomes, contact us today.