Preventing readmissions isn’t just about cutting costs—it’s about delivering better care and keeping patients on the path to recovery. That’s where technology comes in. With better care coordination, stronger communication and proactive follow-up, healthcare providers can keep patients on track and out of the hospital.
In this article, we’ll cover 4 strategies for reducing admissions and highlight how patient education, post-discharge communication and real-time insights can drive better results.

Since this is what CipherHealth’s suite of tools does every day, these strategies are based on our extensive expertise in patient engagement. We’ve successfully reduced readmission risks for nearly 100 top healthcare systems, saving over $500M annually in avoidable costs.

Addressing the Root Causes of Hospital Readmissions

Hospital readmissions put unnecessary strain on both patients and providers. They disrupt recovery, increase costs and often stem from preventable issues like unmanaged chronic conditions, confusion about medications or missed follow-up care.

Reducing avoidable readmissions is a top priority for health systems and hospitals, helping them improve patient outcomes, maintain quality standards and optimize resource use. Readmissions not only indicate gaps in care but also place unnecessary strain on staff and hospital capacity.

So how can hospitals address this widespread issue? It starts with smarter discharge planning, better patient education and seamless care coordination.

When providers use real-time data and proactive outreach, they can catch potential issues early, keep patients engaged in their recovery and prevent complications before they lead to another hospital visit.

Here’s why reducing readmissions is critical:

• Prevents Patient Decline: Addressing issues early helps patients avoid complications and the risk of repeat hospital stays.
• Optimizes Care Delivery: Fewer readmissions free up resources, allowing hospitals to focus on more complex cases and improve overall patient outcomes.
• Boosts Patient Confidence: When patients recover successfully at home, they trust their care team and feel more supported.
• Supports Regulatory Compliance: Meeting performance metrics and reducing readmissions helps hospitals avoid penalties and maintain quality standards.
• Improves Resource Efficiency: Preventing unnecessary hospital stays ensures that beds, staff and resources are available for those who need them most.

By tackling the root causes of readmissions, hospitals can enhance patient outcomes, streamline operations and deliver higher-quality care. With the right strategies in place, patients get the support they need and hospitals can focus their resources where they’re needed most.

4 Strategies for Reducing Hospital Readmissions

Preventing avoidable hospital readmissions requires a proactive approach. Here’s 4 proven strategies to lower readmissions and improve patient outcomes:

1. Improve Discharge Planning and Patient Education

A well-structured discharge plan sets patients up for success after they leave the hospital. During rounding, providers can assess patient understanding of their care plan, address concerns in real time and reinforce key discharge instructions. When patients know what to expect and how to manage their recovery, they are less likely to return to the hospital.

2. Strengthen Post-Discharge Communication

Simply handing a patient discharge papers isn’t enough—active follow-up is key. Checking in with patients after they leave the hospital helps confirm their understanding of care instructions, identify concerns early, and prevent complications that could lead to readmission. Automated outreach and digital tools allow providers to engage all patients post-discharge, so no one falls through the cracks.

3. Improve Medication Access and Adherence

Medication non-adherence is a major driver of hospital readmissions. Patients may skip doses or avoid filling prescriptions due to high costs or confusion about their medications. Implementing a medication affordability program ensures that patients can access and afford their prescriptions, reducing the risk of complications that lead to readmission.

4. Identify and Monitor High-Risk Patients

Some patients are more prone to readmission due to chronic conditions, social determinants of health, or previous hospital stays. Using data-driven tools, healthcare providers can identify at-risk patients and intervene early with additional support, such as remote monitoring or home health services.
The bottom line? Keeping in touch with patients beyond their scheduled visits can help catch potential issues before they require hospitalization.

How Middlesex Health Reduced Readmissions with Proactive Patient Outreach

Middlesex Health, a 300-bed community hospital, used CipherHealth’s post-discharge outreach program to identify high-risk patients and prevent avoidable readmissions. By proactively engaging discharged patients, they provided timely interventions and improved clinical outcomes.

Here are the key results Middlesex Health achieved:

• 20,371 patients contacted, preventing an estimated 120 readmissions
  • Patients who engaged with follow-up calls had lower readmission rates:
  • CHF patients: 3.4% lower readmission rate
  • COPD patients: 9.9% lower readmission rate
• Patient-reported issues were strong indicators of readmission risk:
  • Feeling worse since discharge: 17.2% readmission rate
  • Unclear discharge instructions: 28.3% readmission rate (CHF patients)
  • No transportation for follow-ups: 29.1% readmission rate (COPD patients)

Additionally, the median callback time to patients by care staff was just 1.7 hours, ensuring timely intervention when it mattered most.

Harnessing Digital Tools to Prevent Readmissions

Digital tools help care teams stay connected with patients after discharge, catching potential issues before they lead to readmission. Middlesex Health used automated outreach to identify high-risk patients and intervene quickly, reducing readmissions for those with CHF and COPD. Their success demonstrates how timely follow-up and proactive support can make a measurable difference.

Ready to address preventable readmissions head-on? Schedule a demo to learn how CipherHealth can help your healthcare organization enhance post-discharge communications and drive better outcomes with seamless, data-driven interventions.