Reducing hospital readmissions remains a top priority for health systems—and for good reason. High readmission rates lead to financial penalties, strain clinical capacity and signal gaps in care quality.

Connecting with patients after discharge is one of the most effective ways to prevent avoidable readmissions. But without the ability to adapt quickly, even the best-designed outreach programs can fall short.

That challenge is only growing. CMS is increasing pressure with updates to the Hospital Readmissions Reduction Program (HRRP) and the upcoming Transforming Episode Accountability Model (TEAM), launching in 2026. Under TEAM, hospitals will be held financially accountable for both outcomes and costs across 30-day episodes of care—raising the stakes for timely, patient-centered follow-up.

As patient needs evolve and regulatory demands shift, outreach strategies must be easy to adjust, without placing extra strain on clinical or IT teams.

That’s where CipherHealth comes in. Our platform gives health systems the agility to update outreach programs quickly, reach the right patients and deliver the right message at the right time.

Why Static Outreach Creates Risk

When outreach programs can’t evolve quickly, health systems miss opportunities to prevent complications, especially in high-risk or chronic care populations. Delayed follow-up, generic messaging or limited reach can all contribute to readmissions—and ultimately, lower performance under value-based incentives.

Your organization must ask:

• Are we reaching the right patients?
• Are we engaging patients with a multi-touch, multi-modal approach?
• Are we responding within hours when a patient flags an issue?

If the answer is no for any of these questions, it’s time to rethink your approach.

Why EHRs Alone Fall Short

Health systems that depend on their EHR as the primary method of outreach need internal IT teams to test, maintain and update programs.

What this means:

• High Labor Costs: IT labor is expensive, accounting for a large portion of operational budgets. Hospitals already face record-high labor expenses, with IT and clinical staff in high demand and short supply.
• Delayed Improvements: IT departments juggle critical projects, from EHR upgrades to cybersecurity. Outreach program updates often get pushed down the priority list, causing costly delays that can directly impact patient outcomes and increase readmission risk.

Every delay in updating your outreach is a missed opportunity to prevent a readmission. With TEAM fast approaching, these delays could become more costly than ever.

Smart, Flexible Outreach with CipherHealth

CipherHealth gives healthcare systems the flexibility to act quickly, reduce readmissions and improve patient outcomes. The platform is built for changing needs, making it adaptable without the need to rely on internal IT resources.

Here’s what sets us apart:

• Fast, Automated Outreach: Reach every patient within 24-48 hours of discharge with customizable, condition-specific communications.
• Tailored Communication: Engage patients in their primary language and preferred communication channel—phone calls, text messages or web.
• DRG/Condition-Specific Programs: Set up outreach programs that run for days or weeks, with question sets specifically designed to identify and triage patients based on service line, condition or acuity.
• Real-Time Response: Trigger live support the moment a patient reports an issue.
• Built-In integration: Reduce manual work and documentation by integrating with EHRs and workflow systems, freeing up staff to focus on care.
• Flexible scheduling: Easily adjust the timing and frequency of outreach for different patient groups, whether you’re responding to regulatory changes, shifting population needs or internal goals. No IT tickets required.
• No IT lift: Make changes to enrollment criteria, outreach questions, outreach frequency and language with no internal IT hours required.

Better Engagement, Better Results

CipherHealth is a leader in post-discharge engagement, with deep expertise in helping health systems deliver timely, effective and scalable outreach.

Our platform works alongside your EHR to close key gaps in post-discharge care. 

See how one Midwest-based health system cut undelivered messages by 25,000 per month and reached a 98% delivery rate. Another saved $15 million by reducing readmissions.

With TEAM and more value-based incentives approaching, now is the time to act. CipherHealth gives you the tools to reduce readmissions, improve care transitions and rise to meet the demands of value-based care.

Ready to extend your EHR and improve patients outcomes? Get in touch.