The strategies hospitals are using to prevent readmissions

Modern Healthcare – Thursday, January 29, 2026
By Diane Eastabrook

Health systems are getting smarter on how they handle post-acute care discharges to keep patients from bouncing back to the hospital.

They’re educating clinicians on the most appropriate post-acute setting for patients, adding teams to speed up care transitions and going toe-to-toe with health insurers over referral denials. The added focus on process comes as more providers pivot to value-based care, which rewards them for quality and outcomes.

About 40% of patients receive care in inpatient rehab facilities, long-term care hospitals, nursing homes or from home healthcare providers following a hospital stay. Post-acute care can help patients recover and reduce hospital readmissions. Hospitals face financial penalties if too many patients are readmitted to the hospital within 30 days of discharge.

“There are health systems out there that have done a lot of work in this space, but there are some that simply don’t understand the different levels of post-acute care,” said Brian Fuller, a managing director at healthcare advisory firm ATI Advisory.

Advocate Health was an early adopter of such efforts, having developed a platform in 2009 to to support patients transitioning from the hospital to post-acute settings. The Charlotte, North Carolina-based health system operates approximately 70 hospitals, five inpatient rehab facilities and home health operations across six states.

“It became very clear that if we were going to be managing populations we needed to have a robust platform of programs and services to manage patients longitudinally,” said Denise Keefe, senior vice president of the continuing health division.

Advocate clinicians begin evaluating patients for post-acute services as soon as they enter the hospital. The goal is to discharge patients quickly — ideally to where they live with home care. Those who qualify for additional care are discharged to inpatient rehab or skilled nursing facilities.

Chronically ill patients who cycle in and out of the hospital also may receive in-home physician visits, which Keefe said has reduced hospital readmissions for that group by 50% over the past seven years.

Ohio Health also uses a multidisciplinary team of clinicians, including physical and occupational therapists, social workers and care managers who work with physician leaders to design post-acute transition plans when patients enter the hospital. Care management teams that coordinate referrals develop two separate post-acute pathways based on what the patient’s functional needs will be upon discharge, said Jaimie Kuhne, vice president of care management.

“If the patient is getting a lot of physical therapy while they’re in the hospital, they might not need as much post-acute physical therapy,” Kuhne said. “If the patient is struggling to get out of bed, they are going to need more physical therapy.”

Kuhne said the strategy has helped lower readmissions, but it’s hard to determine the direct impact it is having.

A number of factors can determine where a patient gets post-acute care, including their condition at discharge, access to services, preference and insurance.

Health insurers sometimes deny referrals for post-acute care if they determine patients don’t meet Medicare criteria. Hospitals can successfully appeal denials if they provide robust documentation, said Dr. James Deardorff, a geriatrician and professor of geriatrics at University of California, San Francisco. Deardorff provides clinicial services to UCSF Health Parnassus and at a skilled nursing facility.

“The insurance company might just be reviewing the clinical notes without having underlying background information, like physical therapy and occupational therapy notes,” Deardorff said. “We have definitely been able to work with insurance companies through peer-to-peer discussions.”

OSF HealthCare won 17% of its insurance appeals for skilled nursing services in the second half of last year, a spokesperson said.

However, winning an appeal may not necessarily guarantee a patient admission to a nursing home.

“Skilled nursing facilities look at every single patient and sometimes they’ll deny [an admission] based on the patient’s complexity,” said Matt Nieukirk, OSF HealthCare’s director of operations for home health and skilled nursing.

About 40% of OSF’s patients who can’t get the skilled nursing care they need after discharge are readmitted to the hospital, Nieukirk said.

OSF came up with a workaround that has helped some at-risk patients transition to skilled nursing. The Peoria, Illinois-based health system began a collaboration a few years ago with Puzzle Healthcare. The company deploys clinicians to nursing homes to provide specialized care for more complex patients. Nieukirk said the partnership has helped patients gain access to about 72 nursing homes in Illinois and Michigan, and has cut the readmission rate for those patients to 15%, from about 30%. Puzzle bills Medicare directly for the services.

Access this article at its original source.