Focusing on Post-Discharge Communication and Connected Care to Reduce Readmission Rates

By: Chuck Hayes, Vice President of Product Management for TeleVox Solutions at West Corporation

Driving Better Patient Outcomes

High readmission rates have resulted in steep financial penalties for hospitals and intensified the need for health system providers to become more actively involved in post-discharge care. As the healthcare industry continues to embrace value-based payment models, hospitals are being held accountable for the long-term health of their patients, and they are facing pressure to keep patients engaged, in compliance with care plans, and out of the hospital. With Medicare penalties for hospitals surpassing $520 million this year alone, hospitals are looking to implement strategies that put a greater emphasis on two critical areas: follow-up communication and patient engagement.

Results from a recent West survey revealed that half of acute care professionals feel insufficient follow-up by hospital teams is a leading factor that contributes to readmissions. Another 32 percent of those surveyed suggested that a lack of communication on the part of providers also leads to readmissions. In order to reduce readmissions, hospital and health system providers need to work to keep communication lines open, while also providing meaningful interactions and intra-visit support to those patients that have left the hospital. And all of this must be done in a cost-effective manner.

The idea that providers need to offer more post-discharge support is a sentiment echoed by patients who want to see hospital teams expand long-term support efforts. Medicare’s HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) surveys show that patients often feel disconnected from their medical team after discharge. In fact, recent HCAHPS data reveals that half of surveyed patients reported feeling confused or uncertain about how to comply with care instructions after being discharged from the hospital.

Providers Are Turning to Engagement Communications to Prevent Readmissions

There is mounting evidence that shows post-discharge communications can help reduce readmission rates. For this reason, many organizations have started working to advance communications. That means teams are reaching out to patients that have been discharged, and working to continue supporting patients even after they have left the walls of the hospital.

A first step for many teams is to use automated appointment reminders to encourage patients to see their providers for necessary follow-up care. This is a good first step, but providers need to do much more.

Some hospitals use surveys to gather feedback about patients’ experiences in the hospital. What many hospitals don’t realize is that surveys can also be used to stave off readmissions. Providers can use automated messages to prompt patients to complete short post-discharge surveys about things like medication adherence and pain management. In doing so, healthcare professionals can assess each patient’s risk of being readmitted. When a patient responds to a survey and indicates they are struggling, medical staff can contact the patient, assess the situation, and intervene so that the patient’s condition does not escalate into a critical situation.

This is just one example of how hospitals can use engagement communications to deliver more value to patients and prevent readmissions. The point is, there are opportunities for providers to use technology they already have in place to take patient communication up a notch – and that can help prevent readmissions.

Connected Healthcare’s Role in Reducing Readmission Rates

Healthcare providers are acutely aware that a majority of treatment adherence and disease management occurs outside of the clinical setting. After being discharged from the hospital, many patients require significant lifestyle adjustments. Medical teams can support patients as they make these changes by incorporating technology that connects patients and providers, and creates a feedback loop. Here is an example:

A recently discharged patient dealing with diabetes complications is assigned to a care management program. Using remote biometric monitoring devices (such as heart rate monitors, pulse oximeters, blood glucose meters and other devices), the patient can recover at home while still being closely monitored. In addition to collecting daily analytics on the patient’s physical wellbeing, the care team can also create and schedule a series of automated communications that support the patient’s long-term treatment recovery plan including notifications via email or text when it is time to take medications, schedule routine eye and extremity exams, or a simple text message reminding him to make an appointment for an A1c draw. At any point, if the patient’s vitals indicate signs of distress, treatment is either not being adhered to or there is a risk of complications, providers can then intervene to make sure the patient receives support before experiencing an adverse health event that sends him back to the hospital.

The previous example highlights some of the advantages of using remote technology with automated support in post-discharge treatment plans, how it can help care teams establish critical touch points on when to intervene, and make informed decisions when predicting negative outcomes that may result in a readmission.

The key takeaway is that patients need and desire more intra-visit support. Advanced monitoring technology, comprehensive follow-up plans and tailored communications are becoming vital components in driving better patient outcomes, reducing readmissions and providing health systems the opportunity to earn more reimbursements while avoiding penalties.

About the Author

Chuck Hayes is an advocate for utilizing technology-enabled communications to engage and activate patients beyond the clinical setting. He leads product and solution strategy for West Corporation’s TeleVox Solutions, focusing on working with healthcare organizations of all sizes to better understand how they can leverage technology to solve organizational challenges and goals, improve patient experience, increase engagement and reduce the cost of care. Hayes currently serves as Vice President of Product Management for TeleVox Solutions at West Corporation (, where the healthcare mission is to help organizations harness communications to expand the boundaries of where, when, and how healthcare is delivered.


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