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Effective Patient Engagement Tips to Prevent Hospital Readmission

Organizations may assess risk, drive patient engagement and caregiver education, and account for SDOH to prevent hospital readmission.

Having good hospital readmission rates is nearly impossible without a curated patient engagement strategy.

A key metric in most value-based care models, hospital readmission rates measure the proportion of patients who are readmitted back into the hospital after discharge. Many hospitals look at their readmission rates at different intervals—30, 60, and 180 days—but most payment models primarily look at the 30-day all-cause hospital readmission rate to determine hospital payment.

CMS has led the charge in addressing hospital readmissions through the Hospital Readmission Reduction Program (HRRP), implemented in 2010 as part of the Affordable Care Act. The Medicare Payment Advisory Commission says HRRP reduced hospital readmission between 2010 and 2014. Those decreases leveled off after that. However, when data is risk-adjusted, rates continue to decline.

But there’s still room to grow. According to a 2021 report from the Joint Commission, there were 3.8 million 30-day all-cause adult hospital readmissions in 2018, the most recent year for which it had data. That amounts to a 14 percent readmission rate, costing an average of $15,200 per readmission.

Reducing hospital readmissions can be difficult because it depends on numerous variables. In addition to delivering high-quality care, providers must motivate patients to engage in post-discharge care management and ensure the patient's condition does not unpredictably worsen.

Healthcare professionals can work to reduce hospital readmissions using key patient engagement strategies, including identifying their high-risk patients, engaging them during the care planning process, practicing strong patient follow-up, and addressing the social determinants of health.


Healthcare professionals must first identify which patients are at most risk for succumbing to a medical issue during the recovery process. From there, clinicians can target their engagement efforts to the most high-needs patients.

Clinicians may look at which healthcare conditions yield the highest hospital readmission rates. The 2021 report from the Joint Commission says that in 2018, the hospital conditions with the highest hospital readmission rates included

  • Septicemia, with 314,600 readmissions
  • Heart failure, with 233,100 readmissions
  • Diabetes mellitus with complication, with 122,400 readmissions
  • Chronic obstructive pulmonary disease and bronchiectasis, with 106,300 readmissions
  • Pneumonia (except that caused by tuberculosis), with 97,500 readmissions

There are other flags clinicians should look for aside from medical conditions, like sociodemographics. For example, patients with limited English language proficiency are at higher risk for hospital readmission.

In 2021, data from researchers at the New York University Rory Meyers College of Nursing showed hospital readmission rates for home health patients with limited English proficiency that were two percentage points higher than their English-speaking peers.

Race, too, plays a role. Another study published in February 2023 showed that readmission rates were 34 percent higher for Black heart attack patients than White heart attack patients.

Patients experiencing certain social determinants of health, such as limited transportation access or food insecurity, may also be at risk for hospital readmission because they cannot adhere to follow-up appointment schedules. Low-income patients may not be able to afford the at-home care or medications involved in post-discharge treatment.

Patients with low activation scores may also be less likely to adhere to follow-up treatment.

Healthcare organizations can build their post-discharge follow-up care plans around these considerations. By engaging patients and families during transitions of care and making considerations for the social determinants of health, organizations can improve their follow-up care procedures and reduce the risk of hospital readmissions.


Engaging and involving patients during the discharge process will be essential to ensuring the patient stays healthy during recovery.

Patients can be discharged to numerous different settings, including a rehabilitation facility, a skilled nursing facility (SNF), or the home. Patient and family engagement is important when discharging patients to any facility, but particularly in discharge to home because the patient and caregiver will soon take over care management.

To that end, there’s a lot riding on the discharge process, according to AHRQ.

“The transition from hospital to home can be challenging as patients and families become responsible for care coordination,” the organization says on its website. “Hospital discharges are complicated and often lack standardization. Patients receive an onslaught of new information, medications and follow-up tasks such as scheduling appointments with primary care providers.”

Engaging patients and their family caregivers during care transitions ensures care plans adhere to patient wishes and that patients and caregivers are knowledgeable about certain instructions. Healthcare providers should focus on patient education, ensuring patients and their family caregivers understand their illness, their medications, and other care management plans to foster recovery.

Data indicates that patients who are more involved during the care planning and follow-up process are more engaged in their recovery. In 2021, Boston University Medical Center researchers found that a discharge process emphasizing care coordination, medication management, and caregiver education improved hospital readmission rates.

AHRQ advises healthcare providers to begin the discharge process before the patient is actually discharged to another setting. Patient education throughout the hospital stay is more effective, the agency said. Strategies like patient teach-back will help support education and understanding.

Including numerous care team members, such as nurses, pharmacists, and physicians, will also help ensure tailored patient education during discharge, AHRQ says. All of these efforts can be supplemented by patient discharge checklists, according to the agency.

Importantly, patient discharge needs to include family caregivers, experts agree. Caregiver engagement during the discharge process has the potential to improve readmission rates by around 25 percent.

A separate 2022 meta-analysis of 54 studies showed that hospital readmission rates were better among patients whose caregivers were looped into the discharge process. However, that caregiver engagement only happened around half the time.

Clinicians can engage caregivers by connecting them to community healthcare resources, providing written care plans with medication instructions, and using patient teach-back and at-home procedure demonstrations.

Follow Up Patient Engagement, Outreach

The work to prevent hospital readmission is not done after discharge. After all, patients are still recovering after hospital discharge, so it is important that clinicians can still guide patients in care management during that recovery time.

In some cases, that means better care coordination during the transition to a SNF or rehab facility. In others, it means engaging patients who have been discharged to home.

Either way, maintaining the connection with the patient allows providers the opportunity to advise patients on their path to recovery and flag abnormal recovery early on.

Some healthcare organizations might consider using remote patient monitoring technology to support care management. Some data has shown that tools like home blood pressure monitoring systems can keep some postpartum people from hospital readmissions. Meanwhile, separate data has shown that remote monitoring systems help providers predict hospital readmission and intervene early on.

In other cases, patient engagement will take the form of patient outreach. Through patient outreach, healthcare providers can advise patients about care management plans, answer questions, and check recovery status. For example, one assessment found that patient outreach phone calls helped supplement the patient education delivered during ED discharge.

And like remote monitoring tools, patient outreach checks may help healthcare providers identify acute issues early on and mitigate them on an outpatient basis rather than in the emergency department or hospital.

Traditionally, nurses have been in charge of these patient outreach phone calls. While this approach has been successful in the past, health IT, like automated SMS outreach, has emerged to help ease some burden off of nurses and allow them to refocus on inpatient care.

SMS outreach messages might remind patients about care management plans and ask patients about their recovery. If patients report abnormal issues, the system can refer the patient to a healthcare provider. In a 2022 JAMA Network Open report, researchers found such a text message-based system cut 30-day hospital readmission risk by 41 percent.

Regardless of medium—either text message, patient portal message, or clinician phone call—these outreach systems can also help patients adhere to post-acute care plans. Manual and automated appointment reminders, which are often used to nudge patients to fill care gaps, are also effective for promoting patient access to follow-up care.

Of course, patients often face obstacles to follow-up care management and care access that have nothing to do with the hospital’s engagement strategies. Social determinants of health can serve as barriers to care. By understanding a patient’s SDOH, healthcare organizations may be able to tailor their engagement efforts to reduce readmissions.


Like most areas of healthcare, social determinants of health have a serious impact on hospital readmissions. SDOH can impact patient access to care and patients’ abilities to manage their own care at home, making it a crucial area for organizations looking to improve their hospital readmission rates.

This much is evident by the effect risk adjustment can have on HRRP penalties. In 2022, researchers wrote in Health Affairs that additional social risk adjustment in the HRRP would decrease annual aggregated readmission penalties by $1.7 million for safety-net hospitals.

Said otherwise, social risk plays a big role in hospital readmission rates.

For example, patients who do not have reliable transportation access may not be able to access their follow-up care appointments. Similarly, those with food insecurity or who live in food swamps—regions with limited access to nutritious food—may not be able to adhere to a certain diet involved in their post-discharge recovery.

Right now, there isn’t a lot of data about which SDOH have the biggest impact on hospital readmission. In 2022, an article in the American Heart Association’s journal Circulation: Heart Failure tried to link the nine SDOH listed under Healthy People 2030 with 30-day readmission for heart failure hospitalization, to no avail.

Although the study showed that SDOH does indeed impact hospital readmission rates, the researchers could not identify the particular determinants that sway results.

Still, it is important for hospitals to remain cognizant of the link between SDOH and hospital readmission and design patient engagement programs that can help mitigate those SDOH. Through screening and other data collection methods, hospitals can determine which SDOH most commonly affect their particular patient population and create broad organizational interventions to address them.

SDOH screening may also allow care coordinators or patient navigators to identify individual-level interventions to mitigate SDOH.

Reducing hospital readmission rates will continue to be a high priority as industry professionals look to cut costs and drive care quality. By using strong patient engagement strategies during the post-discharge process, clinicians can reduce the risk of a high-cost readmission.

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