Key Takeaways on Ways to Reduce Hospital Readmissions
Identify patients at high risk early using predictive tools and screenings. Address chronic conditions, mental health, and economic barriers to lower the readmission rate.
Strong post-discharge communication, structured handoffs, and community support reduce hospital readmission rates.
Clear discharge instructions, caregiver involvement, and early follow-ups prevent avoidable returns.
Medication reconciliation, adherence support, and financial assistance help prevent patients from readmitting.
Data analytics and real-time tracking improve coordination across the healthcare system and lower hospital readmission rates.
Preventing infections, maintaining proper nurse staffing, and ongoing training reduce the readmission rate.
Early post-discharge planning, follow-ups, and home health services help keep patients from returning unnecessarily.
Palliative care and advance directives align treatment with patient goals, preventing unnecessary readmission.
Identify High-Risk Patients for Readmission
Identifying high-risk patients early helps prevent avoidable hospital readmission.
Electronic health records (EHR) and health information exchanges (HIEs)Â make it easier to track those most at risk.
Predictive modeling also helps care teams focus on individuals who need extra attention.
Patients with chronic conditions like heart failure and COPD are at greater risk.
Mental health issues, multiple medications, and a history of unplanned readmissions can also affect a patient’s likelihood of returning to the hospital.
Social and economic barriers, such as financial difficulties or limited caregiver support, further increase risk.
The HOSPITAL Score model is a useful tool for assessing readmission risk.
Factors like hemoglobin and sodium levels, recent procedures, and length of stay help care teams decide who needs more support.
Home health agencies can flag high-risk patients early, allowing for better monitoring after discharge.
Behavioral health screenings also play a role.
Early assessments help identify mental health or substance use concerns that might lead to preventable readmissions.
Screening for social determinants of health (SDOH), such as transportation and food insecurity, ensures patients receive the support they need.
Taking cultural beliefs into account helps create personalized care plans that align with patient values.
Strengthen Transitional Care and Handoff Communication
A smooth transition from hospital to home or another care setting reduces readmissions.
Primary care providers need timely updates on their patients to continue treatment effectively.
Sharing real-time data keeps care providers informed so they can take quick action when needed.
Our case study on a hospital’s referral text campaign showed how effective communication at this stage can improve engagement.
Using automated text messages, the hospital reached over 95% of referral patients, reducing the need for multiple follow-up calls.
The result was a more streamlined scheduling process, helping prevent gaps-in-care that often lead to avoidable readmissions.
Texting also made it easier for patients to stay proactive about their care, which contributed to better outcomes.
Multidisciplinary programs, such as BOOST and Project RED, improve handoff communication and ensure continuity of care.
Pre-discharge clinical rounds allow care teams to assess post-hospital needs and create a solid plan before the patient leaves.
Using structured handoff protocols ensures proper communication among teams.
Information about a patient’s condition, treatment, and discharge plan should always be clear and up-to-date.
Skilled nursing and assisted living staff should also receive training to recognize early signs of decline.
Community paramedicine programs provide additional support by offering home visits to at-risk patients.
Transportation and telehealth services help those facing geographic barriers get the follow-up care they need.
Enhance Patient Education and Discharge Instructions
Clear discharge instructions improve patient education and help prevent readmissions.
Simple language and culturally appropriate materials ensure patients and caregivers understand what to do after leaving the hospital.
The teach-back method is a proven way to check for understanding.
When patients repeat care instructions in their own words, providers can clarify any confusion.
Printed and digital copies of discharge instructions, available through patient portals, give patients something to reference at home.
Including caregivers in discharge education strengthens support at home.
Addressing health literacy barriers with customized strategies ensures that patients fully understand when to seek medical attention, how to take their medications, and when to attend follow-up visits.
A follow-up call or telehealth check-in within 48 hours reinforces instructions and provides an opportunity to address concerns.
Improve Medication Reconciliation and Adherence
Medication-related issues are a common cause of readmissions.
A pharmacist-led medication reconciliation before discharge helps prevent errors and drug interactions.
Some patients struggle with adherence due to complex regimens or multiple prescribers.
Identifying these individuals early allows providers to offer additional support.
Written medication instructions should be clear and include dosing schedules and potential side effects.
Tools like automated reminders, digital pill dispensers, and phone check-ins help patients adhere to their treatment plans.
Ensuring patients have access to their medications before leaving the hospital reduces gaps in treatment.
Addressing financial or transportation barriers makes it easier for them to fill prescriptions.
Community health workers and peer support specialists also play a role in helping patients stay on track.
Utilize Health Information Technology and Data Analytics
Real-time updates help care teams monitor high-risk patients.
When inpatient admissions, discharges, and transfers are tracked efficiently, providers can act quickly if needed.
EHRs and HIEs allow healthcare professionals to analyze readmission trends.
Using predictive analytics, hospitals can identify patterns and create targeted interventions to lower rates of avoidable readmissions.
A seamless transition from inpatient to outpatient care depends on effective data sharing.
Primary care providers should receive up-to-date patient records, including medication changes and test results, without delays.
Monitoring medication adherence and chronic disease management through data analytics helps improve long-term outcomes.
Prevent Healthcare-Acquired Infections
Reducing hospital-acquired infections is one way to prevent readmissions.
Pneumonia, catheter-associated urinary tract infections (CAUTI), and surgical site infections are common concerns.
Strong infection prevention protocols include hand hygiene, proper sterilization, and antimicrobial stewardship.
Screening for resistant bacteria like MRSA and isolating affected patients helps reduce the spread of infections.
Hospital staff training on infection control measures should be regular and ongoing.
Electronic surveillance systems help track infection rates and identify problem areas.
Reducing catheter use and following best practices for central line maintenance lower the risk of bloodstream infections.
Proper wound care prevents complications after surgery.
Ensure Adequate Nurse Staffing and Training
Ensuring patients receive the right level of care requires appropriate nurse staffing.
A well-balanced nurse-to-patient ratio improves patient safety and helps prevent readmissions.
Hospitals that improve quality care often focus on retaining experienced nurses.
Competitive compensation, training opportunities, and career development programs help keep skilled staff on board.
Allowing nurses to focus on patient care by delegating non-clinical tasks improves efficiency.
Ongoing training in discharge planning, medication reconciliation, and infection control keeps nurses prepared to address common readmission risks.
Addressing burnout and workload concerns also improves patient outcomes.
Begin Discharge Planning Early and Prioritize Follow-Ups
Discharge planning should start when the patient is admitted.
Creating a plan early helps prevent unnecessary delays when it’s time to leave the hospital.
Our case study on post-op text campaigns showed how automated messaging can significantly reduce follow-up calls while improving patient outcomes.
In this study, an ambulatory surgery center replaced traditional phone follow-ups with automated post-op text surveys.
The results were striking—92% fewer post-op calls were needed, freeing up staff time while ensuring patients received the follow-up support they needed.
Applying this approach to discharge planning can help ensure that patients stay engaged and informed, reducing the chances of unnecessary readmissions.
Follow-up appointments should be scheduled within seven days of discharge.
Timely communication ensures providers can address any complications before they lead to a return visit.
ADT notifications alert providers when a patient has been discharged so they can follow up appropriately.
Multidisciplinary rounds help care teams identify potential discharge barriers and adjust plans as needed.
A follow-up call after discharge reinforces care instructions and provides an opportunity to check for any concerns.
Using predictive analytics and EHR data helps flag patients who may need closer monitoring.
Strong coordination between primary care providers and specialists ensures patients receive ongoing care after they leave the hospital.
Leverage Community-Based Support and Home Health Services
Home visits from a home health agency provide continued care after discharge.
Remote monitoring and telehealth check-ins help track a patient’s recovery and flag potential issues before they become serious.
Our case study on a hospital’s readmission reduction efforts highlighted the impact of mobile messaging on patient engagement.
By using automated two-way texting, the hospital was able to reduce readmission rates by 82% in just 90 days.
The program allowed staff to identify high-risk patients, send targeted messages, and provide necessary follow-up care.
This approach can be extended to community-based support, helping home health services maintain regular contact with patients, address concerns early, and prevent unnecessary hospital visits.
Community organizations, skilled nursing facilities, and assisted living centers offer additional patient support.
Transportation assistance helps patients attend follow-up visits without added stress.
Training community health workers and caregivers ensures they can recognize signs of decline and step in when needed.
Addressing social factors such as housing instability and food insecurity plays a role in recovery.
Community paramedicine programs provide home assessments and offer urgent interventions when necessary.
Integrate Palliative Care and Advance Directives
Discussing advance directives early helps patients make informed decisions about their care.
Palliative care teams support high-risk patients by focusing on comfort and symptom management.
Some patients may benefit from hospice services, and care teams should identify those who qualify.
Interdisciplinary teams work together to assess quality of life and pain management options.
Including goals-of-care discussions in discharge planning reduces unnecessary hospitalizations.
Educating caregivers on palliative care options ensures they understand symptom management and treatment choices.
Documenting patient preferences in EHRs ensures their wishes are honored across all care settings.
Reduce Readmissions Without Adding to Your To-Do List
We know reducing hospital readmissions is a huge challenge—discharge planning, medication adherence, and follow-ups all demand time and resources.
But what if staying connected with patients was as easy as a text message?
With Dialog Health’s two-way texting platform, you can:
Send automated post-discharge follow-ups to prevent complications
Remind patients about medication and follow-up appointments effortlessly
Engage caregivers and community support to keep patients on track
Free up staff time while improving patient outcomes
Let’s make patient communication simple, effective, and stress-free.
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