Tackling readmissions at the root: Why a rural health system is reframing the problem – Becker’s Hospital Review | Healthcare News

A few decades ago, readmissions were seen as a mark of volume. Today, they are a marker of vulnerability. Especially in rural America, they expose the thin edge where clinical complexity meets social fragility.

Ballad Health recently convened a systemwide Readmissions Summit to confront a question that is easy to define but difficult to solve: Why do our patients come back?

It is not just a clinical problem. It is a community one.

In rural communities like ours, where transportation is inconsistent, home health options are sparse, poverty quietly shadows many households, the burden of chronic disease is higher than average, social determinants of health are unfavorable, and bottlenecks often delay discharges to post acute care facilities, the answer is often less about what happened inside the hospital and more about what did not happen outside of it.

And yet, for years, hospitals across the country viewed readmissions through the wrong lens. One more bed filled. One more DRG. One more revenue bump.

That mindset has shifted. Readmissions are now understood as signs of fragmentation, missed connections, and gaps in care continuity.

As part of our commitment to improve outcomes and reduce CMS penalties, Ballad Health brought together leaders from across the system including physicians, nurses, pharmacists, digital care experts, quality teams, and post acute partners to explore the problem and design solutions. Dr. Mark Williams, a nationally recognized internist and expert on care transitions and readmissions, served as the keynote speaker and reminded the group of healthcare’s persistent blind spot: “Nobody is truly responsible for coordinating care.”

The Readmissions Summit focused not on isolated fixes, but on structural changes that prioritize whole person care, community context, and long term trust.

Here are a few key focus areas that emerged from the Summit:

Close the loop before they leave

The discharge process is not just a handoff. It is a hand-holding moment across care boundaries. Strategies include:

• Scheduling all follow-up appointments prior to discharge
• Ensuring CHF patients receive home based nurse practitioner support
• Conducting comprehensive medication reconciliation by pharmacy staff
• Using the teach back method to verify patient understanding
• Identifying transportation barriers and arranging solutions proactively

See the whole person, not just the diagnosis

Every readmission reflects something deeper than a disease. It often stems from unaddressed behavioral health needs, fragmented care, or limited health literacy.

• Social determinants of health are being screened and addressed before discharge
• Palliative care and advanced care planning are being normalized for high risk patients
• Behavioral health is being integrated into post discharge planning and transitions

Redesign care coordination as a systemwide responsibility

Coordination must go beyond departments and handoffs. It must be owned collectively.

• Virtual connections between inpatient care teams and primary care providers are being piloted
• Digital tools are being implemented to support multidisciplinary follow-up and reduce fragmentation
• A warm handoff model is being developed for high utilizers and chronic disease populations

Make data actionable

Data visibility must shift from retrospective reporting to real time insights.

• A systemwide readmissions dashboard is in development
• Predictive analytics, including artificial intelligence tools, are being leveraged to better identify high risk patients and support targeted interventions
• Single contact hubs for patients post discharge are being explored to simplify access

Embed accountability into design

Multidisciplinary teams are shifting from reactive rounding to proactive planning.

• Bedside nurses and pharmacists are being integrated more meaningfully into discharge planning
• Case selection for elective procedures like CABG and joint replacements is being refined
• Discharge education processes are being standardized to improve clarity and consistency

While financial penalties from CMS are real, the deeper motivation is our mission. In rural America, that mission includes bridging the distance between what we can do inside a hospital and what patients face outside of it.

The Readmissions Summit was not a presentation. It was a working session that engaged leaders, surfaced friction points, and aligned the system around solutions that reflect the real world needs of our patients.

Reducing readmissions is not about checking a regulatory box. It is about building a better system that earns the trust of those we serve, one transition at a time.