Preventing Hospital Readmissions with Proactive Patient Outreach

April 7, 2022 | Stericycle Communication Solutions

When patients return home from a hospital stay or an emergency department visit, many do not fully understand what they need to do to follow up on their care. As a result, their condition may become worse, and they may need to return to the hospital and be readmitted for reasons that could have been avoided. Clear communication and outreach can prevent these hospital readmissions.

Learn more about the features of our Medical Call Center Services.

Follow-up with proactive outreach is important for several reasons, not only for initial patient recovery. It helps increase patient satisfaction and loyalty, keeps patients engaged in their care, and prevents hospital readmissions and the associated financial impacts. According to the most recently cited figure from the Centers for Medicare & Medicaid Services (CMS), approximately $17 billion is spent annually on avoidable hospital trips after discharge.

With current staffing shortages, hospital readmissions cause additional strain when patients return due to non-adherence with discharge instructions or immediate issues, such as infection that could have been caught sooner.

Financial Incentives to Reduce Hospital Readmissions

Through the Hospital Readmissions Reduction Program, CMS encourages hospitals to improve communication and care coordination to better engage patients and caregivers in discharge plans to reduce avoidable readmissions. As an incentive, CMS links payments to the quality of hospital care and readmissions of Medicare patients within 30 days in six key areas.

Acute myocardial infarction (heart attack)

Chronic obstructive pulmonary disease (COPD)

Heart failure (HF)


Coronary artery bypass graft (CABG) surgery

Elective primary total hip and/or total knee replacement

In addition, many payors are adding hospital readmission quality measures to their value-based reimbursement programs.

Key Considerations to Prevent Hospital Readmissions

Solving the challenges to follow-up care is important in preventing readmissions. Here are some common barriers to overcome:

Ensure that the patient understands his/her diagnosis, discharge instructions, and medication regimen. Is there a lack of understanding due to limited English proficiency? Is an interpreter service needed?

Communicate the importance of follow-up. Patients may wish to put the medical episode behind them when follow-up care is essential.

Include patient family members in the discussion, when possible, so they understand the next steps.

Assess and address barriers to follow up care. Does the patient have a primary care physician? Transportation hurdles? Can they afford their medication?

Ensure care is coordinated among different settings and providers.

Identify those patients at greatest risk of hospital readmission by looking at such variables as the length of stay, whether the patient has more than one disease or disorder, and whether the patient came through the emergency department.

Additional Post-Discharge Strategies to Ensure Results

Even with the best efforts of hospital staff, there still can be gaps in follow-up care. Improving patient engagement and education is essential, and hospitals do not need to try to tackle it alone.

By partnering with Stericycle Communication Solutions, hospitals can provide comprehensive post-discharge services using digital technology and specially trained agents to support patients in their recovery. Such strategies help prevent hospital readmissions and maximize adherence to follow-up care while reducing the workload for staff.

The array of services includes post-discharge communications with patients that are customized for specific patient populations, clinical departments, and individual providers to develop the content of messages, how often they are sent, on which channel(s), and when.

Highlights of Discharge Services

Connecting patients or their caregivers within 24 to 48 hours of discharge to schedule follow-up appointments and ensure patients understand and can adhere to medication and other aspects of care.

Customized patient surveys to receive feedback and track results to help improve HCAHPS scores.

Real-time connection to clinical representatives when critical questions or issues arise in order to help patients receive assistance or access emergency medical services.

Medication tracking to ensure adherence to the prescribed medications, dosages, and frequency.

Daily text messages to patients for 30 days after discharge with questions about their health status, such as “Are you having any complications today?” The patient can respond whenever convenient, enabling a care provider to intervene when needed.

Outreach if a patient skips a follow-up appointment.

Customized post-discharge patient surveys that provide qualitative and quantitative feedback. Results provide opportunities for improvement and enable hospitals to evaluate and track results.

Results of Comprehensive Post-Discharge Outreach

Another advantage of targeted patient discharge services is to identify patients who may not have a primary care provider and connect them to one within the same hospital system.

With the complexity of healthcare today, patient engagement is more important than ever. By utilizing the comprehensive array of proactive patient outreach tools, it is possible to keep patients on the right path to recovery and wellness and also help ensure a healthy bottom line.

Learn how we can help you reduce hospital readmissions and improve health outcomes.  Learn more.

Previous Back to all Posts Next