The number of hospitals expected to face readmission penalties of 1% or more is expected to rise in fiscal year 2026, according to preliminary Centers for Medicare & Medicaid Services data.

While 7% of hospitals (208) faced penalties in fiscal year 2025, 8.1% (240) are expected to in fiscal year 2026.

Reducing readmissions not only reduces penalties but also helps to improve healthcare and lower costs.

What approaches work to bring down readmissions?

Staying in touch — even virtually — after discharge makes a difference, recent research has found.

Discharge Care Center

While many other readmission reduction programs target a specific patient population, such as older adults or those with heart failure, the Discharge Care Center at Vanderbilt University Hospital in Nashville, Tennessee, is open to all patients who are discharged from the hospital to home.

“We are proud that we are open to serve all patients who are discharging to home or with home health, 24/7, 365 days a year, regardless of patient complexity, risk factors, payor source, or where they live,” said Neesha N. Choma, MD, MPH, executive medical director of quality and patient safety and associate chief of staff at Vanderbilt University Hospital. She is also an associate professor of clinical medicine there.

In its first 2 years of implementation, the center has cared for patients after 80,247 discharges, providing 57,352 clinically relevant interventions, Choma and colleagues reported.

Staff includes registered nurses, social workers, case managers, care coordinators, and pharmacists who are full-time at the center, which operates as an independent care center.

Communication is both patient and staff driven, with patients sharing their phone numbers. The initial automated text message is sent an hour after the discharge order is placed. (If patients prefer phone calls, they can request that.)

The texting continues, with the message on day 1 about medication, day 2 about symptoms, and a message verifying receipt of any medical equipment or home health services. Text messages then continue every 2-3 days for the first 15 days, then taper to every 5 days for a total of 12 across the 30 days (less often if phone is chosen).

Patients are given a number for the center hotline, in operation 24 hours a day, every day, to call with questions or problems.

Readmissions declined from 10.6% (July 2019 to June 2021) to 9.9% (July 2021 to October 2023). The results have held up as cases continue to be reviewed, Choma said.

As for costs?

“Thus far, the cost of operating the Discharge Care Center has been made up for by our ability to prevent some of our more preventable readmissions from returning, thereby opening up those hospital beds for new patients in need of care.”

Virtual Transitions of Care (VTOC) Clinics

Keeping in touch with patients virtually can also reduce readmissions.

A hospitalist-led VTOC clinic at the University of California San Diego Health resulted in significant reductions in readmissions. In a 3-year retrospective cohort study, including 25,443 patients, the overall 30-day readmission rate for those seen in the VTOC clinic was 14.9% compared to 20.1% in the benchmark group not seen in the clinic (P < .001).

The benchmark group included 23,129 patients and the intervention group included 2314 during the study period, from September 2021 through September 2024. The patients had one virtual visit during the 30 days after discharge.

“In our ongoing experience, we continue to see readmission rates that are consistently lower than the benchmark population, which reinforces the durability of our initial findings,” said Milla Kviatkovsky, DO, MPH, clinical assistant professor of medicine and interim medical director of the clinic.

The virtual clinic staff includes 12 hospitalists, two medical assistants, one pharmacist, and an on-demand interpreter service. Discharging providers were automatically prompted at discharge to refer patients to the clinic if they had a LACE + index between 50 and 75, signifying higher risk for readmission. Others with lower scores could also be referred to the clinic.

Medical assistants contacted patients to schedule the video visit.

Kviatkovsky is not surprised by the findings.

“The VTOC model is specifically designed to address many of the drivers of readmission,” she said. “We’re able to identify and manage acute issues early, correct medication discrepancies and ensure patients understand and follow their treatment plans.” The model also allowed for expediting of in-person evaluations when needed.

The bottom line? “These interventions reduce the likelihood that small issues escalate into hospital-level problems,” Kviatkovsky said.

The model may be as effective as traditional transition of care clinics but cost less, she said.

The most substantial reduction in readmissions was found in those with a moderate risk — LACE + scores of 50 to 75. That is also not surprising, she said. “Patients at moderate risk are often the most ‘intervenable’ group. They typically have multiple chronic conditions that require close monitoring but are still responsive to timely outpatient management.”

Now, she said, “we currently see about 100 of the approximately 800 patients discharged,” with hopes of expanding the program.

Expert Input

Programs to reduce readmissions are plentiful and go by many different names, but “the names are more diverse than the interventions,” said Mitchell A. Psotka, MD, PhD, section chief of heart failure and transplant at Inova Schar Heart and Vascular, Falls Church, Virginia. and an expert in readmission reduction.

“The transition of care [time period] is where there is the highest potential for mistakes to happen,’’ Psotka told Medscape Medical News in a telephone interview. Among the common mistakes are missing medications and misunderstandings about follow-up care.

Discharge summaries, he said, are often disjointed and not complete, especially if the patient has had a higher number of clinicians during the stay.

Ideally, any approach for transition of care should focus on three areas, Ptsoka said:

• Being sure the patient has the right medications.
• Being sure the patient is getting proper follow-up, both in terms of frequency and providers. (Heart failure patients, for example, should have a follow-up within a week after discharge.)
• Ensuring the patient has nonmedical needs met, such as being able to pick up medications and get to appointments.

Choma, Kviatkovsky, and Psotka reported having no disclosures. 

Kviatkovsky’s study had no funding. The Vanderbilt initiative was internally funded; the evaluation was partially funded by a grant.