Readmission IQ

Smarter post-discharge outreach to reduce readmissions

Readmission IQ scales your readmissions programs to keep inpatient follow-up care plans on track, addressing both clinical and non-clinical barriers before they lead to avoidable visits.

14%

Readmission rate reduction from 16.5% to 14.2%

33%

Increase in 7-day follow-up appointments from 60% to 80%

7

Average number of interactions per patient

The Strategic Challenge

Limited care visibility across transitions

Health systems invest heavily in care transition teams, yet once patients leave a facility, insight into their status and risk of readmission quickly drops.

Programs struggle to scale effectively due to:

One‑size‑fits‑all outreach ignores diagnosis‑specific risk

Engagement starts only after critical risk signs appear

Post-discharge outreach often limited to just one or two patient touchpoints

Focus on measurable factors while social drivers go unseen

Retrospective reporting explains what happened, not why

The Untapped Opportunity

End‑to‑end visibility into readmission risk

With earlier insight into patient risk and more targeted engagement, teams can focus resources where they will have the greatest impact.

What becomes possible:

Prioritize outreach by predicted timing and drivers of risk

Proactively engage patients before readmission risk rises

Ongoing check-ins during the first 30 days enable early identification and resolution of issues before they escalate.

Tailor engagement to clinical, social, behavioral needs

Measure impact and continuously refine outreach methodology

The Readmission IQ Solution

Smarter identification and escalation of post-discharge issues, focusing intervention where it matters most

Readmission IQ combines predictive analytics, segment-specific outreach and expert navigation to extend and scale existing readmissions programs.

See How We Support Your Care Transition Teams

How Readmission IQ works

Combining people and technology to scale meaningful change and drive greater impact

People

White glove engagement that surfaces real risk

Care Continuity navigators go beyond basic check ins to uncover the true drivers of readmission. Through structured conversations, navigators identify issues related to:

Medication adherence and access

Home health needs or caregiver support

Durable medical equipment gaps

Follow up appointment compliance

New or worsening symptoms

Technology

Granular analytics and root cause insights

Readmissions Assist provides near real time visibility into the factors driving readmissions across diagnoses, cohorts, and care pathways. Reporting enables teams to:

Identify recurring barriers to care transitions

Adjust outreach timing by patient segment

Understand which interventions produce impact

Inform operational workflows and decisions

Working alongside your team

Supporting. Not Replacing.

As all-cause readmissions become a more important performance measure - and health systems seek to improve STAR ratings - Care Continuity works alongside existing care transition teams to scale readmissions management programs.

Patient cohorts are collaboratively defined and assigned to avoid duplication across teams, while clearly established escalation pathways ensure your team remains engaged with the patients who need support most.

The Business Case

Smarter Patient Engagement Drives Fewer Readmissions

By combining predictive insights with proactive outreach, Readmission IQ strengthens existing care transition programs - helping teams intervene earlier, close post-discharge gaps, and prevent avoidable readmissions.

Clinical Quality

Improve care transition outcomes

Close gaps in follow-up care and address barriers before they impact recovery.

Intervene earlier for high-risk patients

Identify high risk patients early and engage frequently to manage issues before they escalate.

Improve patient experience

Increase confidence in recovery, reduce uncertainty, and ensure patients feel supported during the critical post-discharge period.

Financial Impact

Reduce readmission penalties

Reduce avoidable readmissions and improve performance on CMS readmissions measures.

Reduce cost of avoidable visits

Identify and provide earlier intervention to prevent unnecessary ED visits and rehospitalizations.

Improve value-based contracts

Strengthen quality outcomes, including readmissions and follow-up care, tied to reimbursement.

Reduce Readmissions With Smarter Post-Discharge Engagement

Readmission IQ helps health systems proactively support high risk patients, improve outcomes, and scale care transition programs without adding burden to internal teams.