Discharge works. The bottleneck is coordinating the transition without losing the patient between systems.

Hospital readmissions cost 26 billion dollars annually in the United States alone. The CMS HRRP programme penalises hospitals with rates above the national threshold. The average 30-day readmission rate ranges from 14 to 18 per cent, with peaks in heart failure (25%) and COPD (20%). Each avoidable readmission costs between EUR 8,000 and 15,000 in direct costs, plus clinical risk for the patient and deterioration of quality indicators. Generic discharge plans do not work: 50 per cent of patients do not understand discharge instructions and 40 per cent do not attend the follow-up appointment.

CMS HRRP, JAMA Network Open 2025