8 Strategies for Reducing Hospital Readmissions with HRRP

Hospital readmissions are costly — for both patient outcomes and provider finances. And under Medicare’s Hospital Readmissions Reduction Program (HRRP), high readmission rates can also lead to significant penalties.

Reducing readmissions is a critical metric for quality and financial performance. That’s why in this article, we’ll help you with strategies for reducing hospital readmissions.

Here’s what we’ll cover:

• What causes hospital readmissions, and why they matter

• Effective strategies to reduce readmission rates

• How hospitals can comply with HRRP and improve patient care

What is the Hospital Readmissions Reduction Program (HRRP)?

The Hospital Readmissions Reduction Program (HRRP) is a Medicare value-based purchasing initiative designed to improve care quality by reducing avoidable hospital readmissions. Launched in 2012, HRRP penalizes hospitals with higher-than-expected 30-day readmission rates for specific conditions.

Conditions targeted under HRRP penalties

The HRRP targets six specific conditions and procedures: 

• Acute Myocardial Infarction (AMI) 

• Heart Failure (HF) 

• Coronary Artery Bypass Graft (CABG) Surgery

• Chronic Obstructive Pulmonary Disease (COPD)

• Pneumonia

• Elective Primary Total Hip Arthroplasty and/or Total Knee Arthroplasty (THA/TKA)

What is the Medicare 30-day readmission rule?

The Medicare 30-day readmission rule refers to how CMS measures unplanned hospital readmissions. If a patient is readmitted to any acute care hospital within 30 days of discharge for the same condition (or a related one), that admission counts toward the hospital’s readmission rate.

The goal is to track how well hospitals manage care transitions, discharge planning, and follow-up.

CMS uses this metric to assess hospital performance under HRRP and determine whether a facility should receive a payment reduction. Only certain conditions are included, and CMS adjusts for patient demographics and clinical complexity to make comparisons fair.

The impact of readmission penalties on hospitals

In fiscal year (FY) 2023, about 2,300 hospitals were penalized under HRRP — the lowest number in nearly a decade.

However, CMS has updated its methodology for FY 2024 and FY 2025, so more hospitals may see higher penalties due to the reinstatement of pneumonia as a measured condition and expanded data windows.

For FY 2025, preliminary data indicate:

• 71.6% of hospitals will receive penalties of less than 1%

• 7% will be penalized 1% or more

• 21.4% will not be assessed or receive penalties at all

Penalty amounts also differ based on a hospital’s patient mix. Hospitals with a higher share of dual-eligible patients (Medicare and Medicaid) will see an average penalty of 0.31%, while those with fewer dual-eligible patients will face an average of 0.32%.

While these percentages may not seem like much, they can translate into significant losses when applied across a hospital’s entire Medicare reimbursement stream.

Common causes of hospital readmissions

To reduce hospital readmissions effectively, it helps to understand the most common reasons patients return after discharge.

Many readmissions are preventable — not because of a single clinical failure, but because of gaps in how care is coordinated, communicated, and supported across settings. These issues often stem from processes outside of direct inpatient care.

Here are some of the leading contributors:

• Poor discharge planning and lack of follow-up care: Discharge planning that starts too late or lacks structure can leave patients and families unprepared for the transition home. If follow-up appointments aren’t scheduled, or if primary care providers aren’t looped in, patients are more likely to return to the hospital when complications arise.
  
  

• Medication mismanagement and non-adherence: When patients receive new prescriptions — or changes to their existing medications — after discharge, they may not understand what to take, when, or why. Missed doses, incorrect usage, or adverse interactions can lead to avoidable complications and rehospitalizations.
  
  

• Gaps in patient education and self-care: Patients often leave the hospital without a clear understanding of their condition, warning signs, or how to manage recovery at home. Without practical, accessible education, they may miss early symptoms of deterioration or fail to follow care instructions.
  
  

• Insufficient post-acute care coordination: If there’s no smooth handoff between the hospital and the next level of care — whether it’s a skilled nursing facility, home health agency, or rehab center — patients may not get the support they need. Miscommunications or delays during this transition can increase the risk of readmission.
  
  

• Socioeconomic factors affecting patient recovery: Housing instability, lack of transportation, food insecurity, and limited caregiver support can all hinder a patient’s ability to recover safely. Even when clinical care is excellent, these social determinants of health can increase the likelihood of complications that lead to readmission.

8 key strategies for reducing hospital readmissions

Reducing hospital readmissions helps ensure that patients recover safely, stay out of the hospital, and feel supported at every stage of their journey.

For providers, it’s also about creating systems that are clear, sustainable, and less likely to break down under pressure. These strategies focus on the areas where small changes can have a big impact.

1. Strengthening discharge planning

Discharge planning often happens at the tail end of a hospital stay — but by then, it’s usually too late to address what really puts a patient at risk for readmission. Good discharge planning starts early and involves the entire care team with these steps:

• Conduct early risk assessments to identify high-risk patients: Use validated tools or scoring systems to flag patients likely to struggle after discharge — those with multiple chronic conditions, low health literacy, or limited social support.
  
  

• Use standardized discharge checklists to ensure consistency: Every patient should leave with a clear plan. Checklists help make sure nothing gets missed, like follow-up appointments, medication changes, or equipment needs.
  
  

• Provide clear, written, and verbal instructions for patients and caregivers: Avoid medical jargon and make time to answer questions. Use teach-back techniques to confirm understanding. This is one of the most effective ways to prevent confusion that leads to readmission.

Pro tip: Create a standard discharge packet with editable fields for personalized care plans, contact info, medication lists, and follow-up instructions.

2. Enhancing care transitions

A discharge is not the end of care — it’s the start of the next phase. Patients who fall through the cracks during this handoff are the ones most likely to bounce back to the hospital.

Take these steps for better care transitions:

• Implement transitional care programs to support patients post-discharge: Transitional care nurses or navigators can guide patients for the first 30 days after discharge, answering questions and flagging issues early.
  
  

• Schedule timely follow-up appointments within 7 days of discharge: Make it easy for patients to attend these appointments by helping with scheduling before they leave the hospital. Include transportation if possible.
  
  

• Improve coordination with primary care physicians and post-acute care facilities: Faxing or emailing records isn’t enough. Direct, timely communication — especially about medications and test results — prevents gaps in care.

Engaging patients early and consistently can improve outcomes and reduce returns to the hospital — explore these patient engagement strategies that work across care settings.

3. Improving medication management

Medication confusion is one of the most preventable causes of readmissions — especially for older adults on multiple prescriptions.

To prevent medication-related problems:

• Address medication reconciliation errors to prevent adverse drug interactions. Review and reconcile medications at every care transition. Confirm that patients understand what to stop, what to start, and why.
  
  

• Involve pharmacists in the discharge process for accurate prescribing. Pharmacists can catch adverse interactions, clarify instructions, and ensure the prescribed meds are covered by insurance — before the patient runs into a problem.
  
  

• Educate patients on medication adherence and side effects management. A patient is more likely to stick to a regimen if they understand the purpose and know what to expect. Consider sending them home with a simplified meds schedule or blister packs.

Pro tip: Offer a follow-up phone call or telehealth check-in 2–3 days post-discharge focused solely on medication review.

4. Expanding patient education and engagement

Patients are often discharged with complex instructions but little context. Engagement starts with making them active participants in their care, not passive recipients.

These steps are most effective to engage patients:

• Teach self-care techniques to empower patients in managing their conditions: Help them recognize red flags (like weight gain for CHF patients) and understand how to respond before it becomes an emergency.
  
  

• Provide printed and digital resources for post-discharge care instructions: These should be tailored to different learning styles — think printouts, videos, and even patient portals where they can revisit key info.
  
  

• Implement remote patient monitoring to track symptoms and prevent avoidable readmissions: For patients at high risk, daily check-ins via telehealth or wearables can catch early signs of deterioration.

Helpful idea: Host a pre-discharge “what to expect” session for patients and caregivers. Use plain language and interactive questions.

Identifying patients with cognitive impairment using tools like the BIMS score can help tailor discharge plans and post-acute care to reduce readmission risk.

5. Leveraging technology and data analytics

Not all readmissions are predictable — but many are. Hospitals can spot risk factors early and intervene before problems escalate using tools like these:

• Use predictive analytics to identify and monitor high-risk patients: Analytics platforms can flag patients likely to return based on diagnosis, comorbidities, and social risk factors — giving your team time to act.
  
  

• Implement telehealth interventions for follow-up care and virtual check-ins: Not every patient can make it to an office visit, but nearly all have a phone. Virtual visits can bridge care gaps and keep patients connected.
  
  

• Use digital tools for real-time patient tracking and automated alerts: Alerts for missed appointments, symptom reports, or medication gaps allow you to intervene early.

Pro tip: Start small — run a pilot program for one condition (e.g., COPD) using remote monitoring and track readmission trends over 90 days.

6. Addressing social determinants of health (SDOH)

Clinical care doesn’t exist in a vacuum. Many readmissions are tied to external factors hospitals don’t always see — like housing, income, or food security. Here’s how to help with these other factors:

• Connect patients with community-based support services (transportation, food, housing). Partner with local agencies to make sure patients have access to essentials post-discharge.
  
  

• Address financial and social barriers that may prevent follow-up care. Include social workers or care managers in discharge planning to identify these issues early.
  
  

• Provide mental health support and access to counseling services. Depression, anxiety, or untreated mental illness can sabotage recovery. Screening and referral should be routine.

Helpful idea: Build a local resource directory that your discharge planners can use when referring patients to community organizations.

7. Strengthening in-hospital care quality

Preventing hospital readmissions starts with improving care during the initial stay. That means reducing complications, catching early signs of deterioration, and preparing patients for what comes next.

Remember to maintain care quality by:

• Implement early warning systems to detect and manage patient deterioration. Tools like MEWS or NEWS can alert staff to subtle changes before they lead to a crisis.
  
  

• Reduce hospital-acquired infections that contribute to readmissions. Strict infection control protocols, especially for surgical and ICU patients, can dramatically reduce complications after discharge.
  
  

• Ensure proper staff training to improve patient safety and post-discharge preparedness. Empower nurses, case managers, and ancillary staff with tools to assess readiness for discharge and educate patients effectively.

Pro tip: Create a checklist for nurses to review with patients before discharge — covering everything from wound care to medication use.

8. Expanding post-discharge support programs

Patients often leave the hospital with limited support, and that’s when things can go wrong. Ongoing touchpoints help catch issues early and keep patients on track, so try these tips:

• Develop home health programs for post-discharge monitoring and care. Even short-term home visits can prevent complications and reassure patients and families.
  
  

• Engage family caregivers in training and support groups. Most care happens at home. Give caregivers the tools they need to feel confident and supported.
  
  

• Partner with skilled nursing and rehabilitation centers for extended care when needed. When patients can’t recover safely at home, SNFs and rehab centers offer the structure and supervision that make readmissions less likely.

Helpful idea: Set up a post-discharge hotline or triage team that patients can call with questions. Many readmissions start with a small issue that could’ve been solved with a 5-minute conversation.

How do predictive analytics improve hospital readmission prevention?

Predictive analytics gives care teams something they rarely have enough of: foresight. Instead of waiting for a complication to send a patient back to the hospital, predictive models help identify who’s at risk before problems start.

These tools analyze patterns in patient data — diagnoses, comorbidities, medication lists, social risk factors — to surface red flags that might not be obvious in the moment.

For example, a patient with COPD and a recent ED visit might not look high-risk on paper, but predictive algorithms can detect subtle combinations that suggest a higher chance of readmission.

When used effectively, predictive analytics helps care teams:

• Focus resources on patients who need the most support.

• Trigger targeted interventions like earlier follow-up visits or remote monitoring.

• Prioritize transitional care for complex discharges.

• Spot system-level trends that contribute to readmission risk.

These insights aren’t meant to replace clinical judgment — they’re meant to enhance it. And when paired with good workflows and communication tools, they make it easier to intervene early, track outcomes, and continuously improve.

Reducing hospital readmissions with ExaCare’s data-driven approach

Preventing readmissions starts with getting the right patient to the right facility at the right time. But for most skilled nursing and post-acute care providers, that’s still easier said than done.

Admissions teams are juggling multiple portals, scanning through referral packets by hand, and trying to make complex decisions on the fly — all while hospitals are waiting for an answer.

ExaCare changes that. Our platform uses AI to streamline the entire admissions process, from the moment a referral arrives to the second you say yes. We help teams make faster, more accurate decisions so patients don’t fall through the cracks, and hospitals don’t move on to the next facility.

Here’s how we support better outcomes and fewer readmissions:

• AI-powered referral screener that parses long referral packets in minutes, surfacing key clinical and financial details
  
  

• Built-in analytics to help track your referral response times, denial reasons, and hospital performance metrics
  
  

• Automated insurance verification and medication cost flags to ensure every admission makes financial sense
  
  

• Clinical decision support that highlights high-risk cases and supports your team in making confident, compliant choices
  
  

• Communication tools to streamline collaboration between admissions, nursing, and leadership teams

Facilities using ExaCare see faster response times, avoid low census, and can build stronger hospital partnerships. Most importantly, they’re better equipped to accept the right patients and help them stay out of the hospital after discharge.

Want to see what that looks like for your facility?

Schedule a demo.