A valuable asset in reducing readmission rates

Providing coordinated transition of care services

Reducing Hospital Readmission Rates

HRSI is dedicated to reducing readmission rates improving patient health during transition of care.

The Affordable Care Act requires the Centers for Medicare & Medicaid Services to reduce payments to hospitals with excess readmissions within 30 days of discharge for acute myocardial infarction, heart failure, and pneumonia. By lowering these preventable readmission rates, the Federal government projects a savings of $26 billion in the next few years. Effective transition of care programs will reduce these readmissions by improving the care coordination for patients as they move from one healthcare setting (e.g., hospital, rehabilitation center) to another.

The Problem

  • Fragmented patient care during transition from one healthcare setting ot another
  • Poor communication between health care settings
  • Patient confusion about their chronic illness and how to manage their health
  • Medication errors typically involve patients not following the dosage protocol, patients not taking the medication, or patients experiencing drug interactions
  • Poor follow up with the primary care provider
  • Lack of patient knowledge about social service benefits to which they may be entitled


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The HRSI Solution

Hospital Services

Through the use of our EDGE and Medical Assistance Tracking System (MATS), as well as our call center, HRSI is a valuable asset in reducing hospital readmission rates. Here is how it works:

  • HRSI incorporates patient data, as well as information on medications, private foundation benefits and grants, and disease-specific programs into MATS. This provides an effective basis for a high-risk patient tracking system.
  • We use our call center and field-based representatives for patient follow-up. This ensures that patients have their medications and are taking the appropriate dosage. In addition, HRSI sets up and/or provides transportation for physician office visits.
  • With the HRSI transition of care service, both hospitals and patients benefit. Hospitals have more available staff hours to treat patients and the ability to reduce readmission rates, while patients receive the most coordinated care possible.