Background: Reducing 30-day readmissions for CMS-targeted conditions—pneumonia, AMI, COPD, and CHF—remains a national priority. While our hospital historically maintained strong readmission performance for fee-for-service patients, rates rose sharply from 9% in 2023 to 16% in 2024. This prompted a hospital-wide reassessment and the launch of a multidisciplinary initiative to identify system gaps, standardize transitions of care, and reduce avoidable readmissions in these high-risk CMS cohorts.
Purpose: To implement a multidisciplinary process, with hospitalists and case management taking the lead, centered on early patient identification, a unified transition checklist, and real-time review of re-presentations to reduce avoidable 30-day readmissions for CMS-focused diagnoses.
Description: A multidisciplinary team comprising of hospitalists, nurse managers, case managers, social workers, pharmacists, ED clinicians, palliative care, and quality management collaboratively designed and implemented a standardized protocol to reduce 30-day readmissions. Fee-for-service patients with CMS-targeted conditions were identified daily via a “Star Chase List”, jointly monitored by hospitalists and case managers. During daily interdisciplinary rounds, these patients triggered the application of structured transition-of-care protocol. Hospitalists conducted goals-of-care discussions, facilitated 30-day “meds-to-beds” delivery, and provided warm handoffs to PCPs or post-acute providers. Social work assessed social determinants of health and provided caregiver support to patient’s families. Case managers secured 7-day follow-up appointments and completed 72-hour post-discharge calls with an escalation pathway to hospitalists for clinical concerns.For any 30-day re-presentation to the ED, an automated Microsoft Teams alert notified ED providers, hospitalists, and case management, prompting an online huddle to assess whether the patient could safely return to the community. If readmission proceeded, the case was reviewed at the monthly Readmission Committee to evaluate quality of care on index admission and to identify improvement opportunities.During the 8-month pre-intervention period (January-August 2024), 20 readmissions were recorded. Following implementation of our novel transition of care protocol, this number dropped to 5 readmissions during the equivalent period in 2025, representing a 75% overall reduction. The scalability of this approach offers a clear pathway to substantially lowering avoidable readmissions hospital-wide, aligning with value-based care goals and enhancing operational efficiency.
Conclusions: A coordinated hospitalist-driven model, supported by case management and ED collaboration, can significantly reduce avoidable readmissions. Real-time patient identification, a standardized transition checklist, early follow-up, and rapid re-presentation review create a reliable system that strengthens care continuity and addresses root causes of readmission. This scalable framework supports CMS goals and demonstrates how hospitalists can effectively lead high-impact improvements in transitions of care and readmission prevention hospital-wide.