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30-Day Readmission Prediction Engine

Stop the revolving door before patients bounce back

At-Discharge Scoring

Risk score generated within hours of discharge notification

Intervention Protocols

Automated care transitions for high-risk discharges

Penalty Avoidance

Reduce Medicare readmission penalties and commercial trends

The Readmission Tax

28% of inpatient discharges return within 30 days—75% are preventable with proper post-acute care. Each readmission costs another $15K-$25K plus Medicare penalties if your rate exceeds national benchmarks. Traditional discharge planning is one-size-fits-all ("everyone gets a follow-up call"). Our engine identifies which discharges will actually bounce back so you can deploy intensive care transitions where they matter.

The $1.8M Readmission Burden

Baseline Readmissions (No Intervention)
  • • 200 annual discharges across plan population
  • • 28% readmit within 30 days = 56 readmissions
  • • Avg readmission cost: $18,000
  • • Annual readmission cost: $1.008M
  • • Plus Medicare penalties if applicable
With Prediction + Care Transitions
  • • 80 discharges flagged high-risk (40% of total)
  • • Intensive transitions: home health, 7-day PCP follow-up, med reconciliation
  • • 70% reduction in high-risk readmissions
  • • 25 readmissions prevented = $450K savings
  • • Intervention cost: $1,200/high-risk discharge = $96K
  • • Net savings: $354K

Why Readmissions Happen (And How to Stop Them)

Medication Errors Post-Discharge

40% of readmissions trace to medication issues—wrong dose, drug interactions, patient didn't fill Rx, confused about new regimen. Hospital discharge instructions are overwhelming; patients forget or misunderstand.

Prevention Protocol: Pharmacist visit within 48 hours of discharge for medication reconciliation + teach-back on new Rx regimen

No PCP Follow-Up

Patients discharged without scheduled PCP appointment within 7-10 days are 3x more likely to readmit. Primary care catches complications early before they escalate back to ER/inpatient.

Prevention Protocol: Care manager books PCP appointment before discharge, calls day before to confirm patient will attend

Social Determinants

Patient can't afford Rx copays, has no transportation to follow-up appointments, lives alone and can't manage ADLs post-discharge. Clinical issues compounded by social barriers.

Prevention Protocol: Social worker assesses barriers, arranges copay assistance, medical transport, or short-term home health aide