Redefining Readmissions: A Continuum of Care Responsibility

By Lakmali Ranathunga, MD, chief medical officer, Miami Valley Hospital North, Upper Valley Medical Center

Preventing 30-day readmissions can no longer be viewed solely as the hospital’s responsibility. Instead, it must be reframed as a shared accountability across the entire continuum of care, including extended care facilities, FQHCs, food banks, home health care agencies, and primary care offices. The burden of keeping patients out of the hospital must be shouldered collectively by every organization that touches the patient before, during, and after an acute episode.

This is not simply about reducing a metric, it’s about building a seamless care ecosystem. The partnerships between hospitalists, ED providers, primary care physicians, specialists, home health agencies, and community organizations are crucial. Every transition—whether from hospital to home, SNF to clinic, or ED to primary care must be anchored in a tightly coordinated care plan that supports both medical and non-medical needs.

Palliative care must be integrated more intentionally into this framework. A significant proportion of readmitted patients are in the final chapter of life, often returning to the hospital multiple times before they pass. Ensuring timely alignment with palliative care and hospice services can not only reduce readmissions but vastly improve the patient and family experience during end-of-life care.

In addition, social determinants of health, such as food insecurity, transportation barriers, housing instability, and caregiver availability, must be proactively addressed. These are not peripheral issues; they are often the root cause of avoidable readmissions.

While we are currently engaging stakeholders across the continuum of care, gaps in our transitions persist, resulting in lost lives, resources, and trust. Our next step is to intentionally connect these loose ends through shared accountability, data exchange, proactive outreach, and a unified care coordination framework.

Ultimately, preventing unnecessary readmissions requires a system where every patient transition is supported, every care plan is connected, and every community partner is aligned. When a patient begins to face a terminal diagnosis, we must ensure that palliative care and community-based supports are activated early and effectively to provide compassionate, coordinated, and appropriate care at the end of life.

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