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Nearly 20% of Medicare beneficiaries discharged from the hospital face hospital readmissions within 30 days, costing the health system more than $26 billion a year, with an estimated $17 billion of that avoidable. Four of the eleven APG Spring 2026 case studies tackled care transitions head on.
UCLA Health: Redesign the Workflow
UCLA built an EHR-integrated care transitions workflow that flags patients at admission, standardizes discharge checklists, and assigns an ambulatory team to own post-discharge outreach. Since the July 2023 redesign, hospital readmissions dropped 3% and ED visits 28% versus a control group, while 7-day follow-up rose from 27% to 32%.
UC San Diego: Meet Patients at Home
UC San Diego's ED Transition of Care program gave discharged patients a televideo visit with an emergency physician within 72 hours, backed by home health, in-home diagnostics, and physical therapy. ED revisits fell at every interval, reaching 20.4% versus 22.9% at 30 days.
John Muir Health: Move the Intervention Upstream
By embedding palliative care clinicians in the ED instead of waiting until day four of admission, John Muir cut average length of stay by 4.8 days (6.9 versus 11.7). Across 156 consults, they avoided 542 excess days and earned a 7.2x return on ED labor, about $921,000.
Vivant Health: Redesign the Finances
Vivant assumed partial capitated risk for post-acute costs on a Sacramento Medi-Cal population, restructuring the financial incentives around care transitions. Mercy San Juan's readmission rate dropped from 20.9% to 10.5% over six quarters, a 49% cut, and 7-day follow-up rose from 76% to 96%.
The Takeaway
Different models, same lesson. Own the handoff, or lose the patient. Reducing hospital readmissions starts with treating care transitions as a system to design, not a gap to hope patients fall through the cracks of.
Post-discharge patients frequently need follow-up imaging, and that's exactly where they slip away: scheduling is hard, prior auth is slow, and they don't know where to go. Medmo manages diagnostic imaging referrals end to end, so a discharge plan doesn't stall at the scan.
*Medmo partners with ACOs, IPAs, PCPs, and FQHCs to manage diagnostic imaging referrals end to end: scheduling, prior authorization, patient outreach, and results retrieval. To learn more, visit medmo.com.*
