Many of us are doing an amazing job managing patients and keeping them out of the hospital. I want all of you to realize that we may not be doing enough to make a significant difference.

What I have noticed is that we have made an impact, but many patients that end up being hospitalized were not appropriate for discharge or were not referred for our services. 

Check out some of the data that CMS has published about how much money they spend on hospital readmissions.  It is quite shocking.

  • CMS penalized over 2,500 hospitals by more than $564 million in 2017 for excessive 30-day hospital readmission rates
  • Readmissions of privately insured and Medicaid beneficiaries cost $8.1 billion and $7.6 billion, respectively
  • Medicare spent $14.3 billion on 1.3 million hospital stays associated with hospitalizations of nursing home residents. These costs represent 11.4% of Medicare Part A spending on all hospital admissions ($126 billion) in the same year.
  • Medicare spent an average of $11,255 on each hospitalization of a nursing home resident, which was 33.2% above the average cost ($8,447) of hospitalizations for all Medicare residents.

Data shows home health visits can reduce the likelihood of hospital readmission by as much as 25%. Successful home health care staff members and private duty home care agencies work as teams to monitor patients for potential health problems and together have the best outcomes of keeping patients out of the hospital. When integrated into the continuum of care, home health helps ensure that patients discharged from acute care settings and skilled nursing facilities do not suffer relapses that require rehospitalization.

The stakes are high with hospitals and health systems facing financial penalties under Medicare’s Hospital Readmission Reduction Program for a half-dozen conditions including heart attack, pneumonia, and coronary artery bypass graft. Beyond the HRRP penalties, readmissions increase the total cost of care and decrease the patient’s quality of life.  Here are some additional findings about readmissions that I think are significant:

  • Recent data from Paramount—a health insurance company affiliated with Toledo, Ohio–based ProMedica—shows that patients who utilize home health services within 14 days of discharge from an acute care facility are about 25% more likely to avoid a readmission within 30 days of discharge.
  • In a systematic review of heart failure patients published in the Annals of Internal Medicine, home nursing visits reduced readmissions and mortality for as long as six months.
  • In an observational study published in the journal Health Services Research, a combination of home health services and clinician visits decreased the probability of readmission by 8%.
  • In a study published in the Journal of Post-Acute and Long-Term Care Medicine, patients discharged from skilled nursing facilities to home care with a home health visit within a week of SNF discharge had a reduced hazard of hospital readmission

Home Care Sales has been working on post-acute care collaborations with teams that we mentor in our Mastermind Program. We know what metrics matter. You need to be thinking about what steps you can take to improve your readmission rates at your organizations. Capturing and sharing this information with your referral sources will make a difference in how they consider your agency over others. 

With readmissions, there are massive reasons for hospitals, skilled facilities, and LTACs (among others) to engage the services of home health, hospice, and home care as outlined in the statistics above. So what happens when your team gets their “moment” with a decision-maker at a referring facility? If they can’t spell out the ways your agency is benefiting thier patients and improving the overall process of referring, then you are at risk to lose some serious opportunities.

Train your team to know what to say when they get an opportunity. Show them how to turn a meeting into a referral. If you need help, we can absolutely help. Reach out to for more details.

I wish that home care sales existed back in 1995, when I was opening my first agency. I would have had a much easier time growing. I would have had the tools that I needed to help get patients identified every time. I would have known the exact words to trigger referrals. 

The good news is folks, we are here for you now! Go to and check out the Mastermind Program, and the incredible programs that we have that will help stop the readmissions! Let’s get every patient that needs and deserves your services identified and treated by your organization.