Readmissions happen—not because of shortcomings with your physicians or nursing staff—they happen because the gaps that drive readmissions occur in the community, outside of your visibility, care, and connection to the patient. In a recent Guideway Care analysis of close to ~1000 navigated patients, the two biggest drivers behind readmissions were scheduling follow-up appointments and medication adherence, both of which were heavily influenced by transportation needs and financial challenges. There is no way for your clinicians to find every gap for every patient AND engage the resources needed to fill the practical, emotional, and financial barriers that bring patients back to the hospital—not at scale and not cost-effectively.
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