Hospital readmissions increase costs, strain limited resources and may signal gaps in care transitions. In fact, nearly 20% of patients return to the hospital within 30 days of discharge.
Understanding readmission rates in healthcare requires looking beyond clinical care to the administrative systems surrounding discharge and follow-up. Healthcare managers play an important role in reducing hospital readmission rates by improving workflows, coordination and transitional care.
Hospital readmissions are often described in the context of clinical challenges. Many patients are readmitted due to flare-ups from chronic conditions, although infections and harmful drug interactions can also force patients to return. When we only examine the clinical side of readmission, however, we miss out on the big picture, including the large-scale practices that make such clinical challenges more likely in the first place.
Data compiled by the Agency for Healthcare Research and Quality (AHRQ) suggests an average cost of $15,200 per readmission, although this varies based on the diagnosis and the reason for readmission. For example, when complications from transplanted organs lead to hospital readmissions, they cost $27,000, on average, over the course of thirty days. Meanwhile, readmissions tied to septicemia cost an average of $15,000.
Clinical teams can address medication issues, complications and other immediate risks, but they cannot resolve every systemic cause of readmission alone. Healthcare managers help establish staffing, documentation, communication and discharge workflows that give clinicians the support needed to provide coordinated care.
We are in the midst of a profound change in how clinical services are perceived and how they are billed. The once-dominant value-based care model generated greater revenues as more services were offered. In other words, the more tests and the more procedures, the more billing opportunities.
The flaw in this arrangement is that more is not always better. Hence, the shift towards value-based care, in which financial outcomes are more closely tied to health outcomes. As the Centers for Medicare & Medicaid Services (CMS) points out, this approach emphasizes "person-centered, coordinated care," with a central goal of improving the patient's overall experience.
Under this approach, limited readmissions are prioritized because they limit the potential for Medicare penalties and even open the door to incentive opportunities. The coordinated, proactive strategies that lead to fewer readmissions also limit waste such as duplicate tests or excess administrative processing.
Generally speaking, patients return because clinical care does not entirely resolve their medical challenges or because new issues develop in response to previous treatments. Many factors contribute to these deficits:
A wide range of clinical issues can lead to readmission, but AHRQ data suggests that this problem is more common when certain diagnoses occur at initial admission: septicemia, heart failure, diabetes and renal failure, among others. Readmission risks are not tied exclusively to diagnoses, however. Errors or systemic gaps lead to avoidable readmissions. Common issues include medication errors, delayed diagnoses, rushed discharges and fragmented communication.
When we view hospital readmission as a public health concern, we gain a better understanding of the broad factors that shape patient outcomes, even when both clinical and administrative teams appear to do everything correctly. Too often, however, we assume that patients have access to resources or support that accelerate their recovery, when, in reality, many see health challenges exacerbated by difficult social and economic realities.
Households and communities suffering from food insecurity struggle to access sufficient quantities of nutritious food. This does not always involve the physical sensation of hunger. In fact, food insecurity is often a risk factor for obesity. Meanwhile, many patients struggle to access clean drinking water, leaving them at risk of gastrointestinal illness.
Patients who lack reliable transportation may struggle to access follow-up visits that might otherwise pinpoint complications early on, when they can be treated outside the hospital. Many also face housing instability and are therefore unable to properly store medications or maintain hygiene practices that prevent infection.
Patients could receive well-designed instructions and still struggle to follow clinical recommendations because they simply don't understand them. Language barriers are often at play, as are literacy concerns that make medical terms or dosage information difficult to navigate. Social isolation compounds these issues when patients cannot turn to loved ones for guidance.
This work is already underway at NMC. Bryce Kennedy, a candidate in NMC's Public Health Policy Ed.D. program, is using his Doctoral Scholarly Project to drive real change for LEP patients. He is writing custom R scripts to conduct an equity audit of his hospital system's emergency room, and his findings will live on as an "equity dashboard" the system can keep using after his project ends.
The project calls for "a shift to equity-based metrics," meaning that instead of looking only at averages across all patients, leaders compare how different groups of patients move through care. Ongoing, data-driven tracking like this is exactly what healthcare managers need to find where language barriers slow care before those delays show up as readmissions. It also shows what NMC's doctoral programs are built for: working leaders applying their research in real time to improve care for real patients.
Watch Bryce's story on NMC's Instagram and leave a comment of encouragement as he finishes his project.
The potential path to readmission begins as soon as patients leave the hospital. Discharge should not be regarded as the end of the patient's hospital journey. Rather, this represents a crucial point of transition, when patients begin to play a greater role in managing their own care. This is a common point at which continuity of care diminishes, but, with the right discharge practices, such gaps need never emerge.
Readmissions are not always as they seem. They rest at the intersection of clinical, administrative, economic and even social challenges that must all be addressed. Difficult truths at the heart of contemporary clinical care include the following:
Clinical professionals are often not to blame for high readmission rates. Yes, clinical oversights are possible, but these are far more likely to occur when systemic pressures prevent clinical teams from providing the targeted and attentive guidance that patients deserve.
At discharge, patients are often excited to return home and also hopeful because their physical suffering seems to have diminished. In reality, these apparent improvements often mask deeper issues that, if not addressed, could leave patients at even greater risk. Should continuity of care disappear, such underlying issues are allowed to compound until readmission becomes inevitable.
The 30-day window is widely used as a standardized performance benchmark, including in Medicare programs, but readmission risk does not disappear after day 30. Healthcare organizations should therefore monitor short-term performance while recognizing that chronic conditions may create risks beyond this reporting period.
Healthcare managers draw on peer-reviewed studies and facility-specific data analysis to reveal which discharge processes improve patient outcomes and reduce overall readmission rates. Strategic workflow design allows them to uncover points of friction, often while mapping patient journeys or examining current discharge protocols.
Standardized discharge processes form a reliable framework to help all patients successfully transition between care settings. Because there are so many moving parts, clinical professionals require a solid blueprint and easy-to-follow processes that improve care coordination and limit communication gaps. Discharge checklists guide reconciliations while clarifying instructions and arranging for follow-up appointments.
Discharge must be a collaborative process, drawing on the expertise of the primary medical team along with support from bedside nurses. On the logistical side, discharge gains consistency when guided by case managers or dedicated discharge planners. Hospital pharmacists are increasingly central to this effort, guiding not only medication reconciliations, but also patient education.
Patient education should not simply be a matter of reciting checklist items out loud. This is a valuable opportunity for connection, in which patients are encouraged to voice their concerns or address any instructions they find confusing. Protocols should be flexible enough to account for patient-specific concerns while still improving consistency across care teams.
Because such a significant share of readmissions relate to medication errors, reconciliation must be a priority. The prescribing physician reviews medication lists and updates medications as needed, but reconciliation should also involve input from the hospital pharmacist, who verifies dosing and checks for potentially harmful interactions.
While care transitions are often discussed in the context of moving from the hospital to home, many patients receive additional care within rehabilitation centers or in nursing facilities. Others rely on home health care, receiving daily visits from nurses who provide critical support as they monitor recovery. These post-acute settings require seamless handoffs because the ripple effects can escalate quickly, leading to missed doses or delayed interventions.
Transitional care management (TCM) describes how potential care gaps are addressed as (and after) patients are discharged from the hospital. This involves a carefully planned and coordinated series of points of contact that keep patients (along with inpatient and outpatient providers) fully informed and invested in maintaining quality care.
All patients should have the opportunity to chat with primary care providers within at least 72 hours of leaving the hospital. They should not be expected to initiate contact on their own. Post-discharge calls provide a chance to confirm that patients still understand discharge instructions and that their condition remains stable.
Discharge calls are helpful but may not uncover signs of trouble quickly enough or could miss them altogether if patients downplay their condition. Through patient monitoring, clinical teams gain a more granular understanding of how patients are faring and where adjustments might prove necessary. This effort increasingly relies on wearable technologies, which limit the need for patients to send manual updates.
High-risk patients may benefit from structured follow-up appointments that allow providers to identify complications, reconcile medications, reinforce self-management skills and order additional testing when needed. Research suggests outpatient follow-up may help lower readmission risk for some patient populations.
Community health workers address the social manifestations of disability and disease, determining how issues such as housing instability, food insecurity, pollution or social support may impact health outcomes. While these issues are often analyzed and addressed on a broad scale, individualized attention allows care teams to adjust plans based on patient-specific challenges. For example, food insecurity makes it difficult to manage chronic conditions (like diabetes) but community health workers recommend nutrition programs and other resources.
Closed-loop referrals prioritize two-way communication, prioritizing follow-up communication to confirm that patients actually connect with the resources or services to which they're referred. These setups involve designated points of contact, responsible for receiving and following up on referrals. Platforms and data-driven tools allow teams to track these efforts in real time, with patterns revealing opportunities to improve communication and patient engagement.
Nebraska Methodist College (NMC) empowers tomorrow's healthcare leaders to design and implement policies or practices that make a real difference in patients' lives. Our healthcare administration programs build analytical and strategic skills, which, in turn, help future leaders identify (and resolve) barriers to care. Learn more about opportunities at NMC and discover a meaningful future in healthcare administration.
Nebraska Methodist College (NMC) specializes in healthcare with programs in nursing, allied health and healthcare management.
NMC offers certificate, undergraduate and graduate healthcare programs.
Discover Our Healthcare Management Programs
At NMC, you can earn your: