CASE STUDY

Reducing Hospital Readmissions for Medicare Patients

Challenges

Medicare penalties for excess readmissions for CHF, COPD, pneumonia, and AMI
Lacked post-discharge resources and technology to engage discharged patients
Readmission penalties tied to a three-year performance window
Cost and risk of building a program internally with no guaranteed results

Outcomes

Readmission rates were decreased with each diagnosis well below hospital’s benchmark
Defined process for identifying and referring eligible patients
Proven outcomes secured without taking on internal cost or risk
Repeatable 30-day model carried into future hospital partnerships

Client

Pioneers Memorial Healthcare District

Type

Rural Hospital

Populations

Medicare and Medicaid

Pioneers Memorial Healthcare District manages Medicare patients discharged with CHF, COPD, pneumonia, and AMI. With CMS penalties based on three years of readmission history, the hospital needed a fast, low-risk alternative to building a program internally.

Avery Telehealth partnered with Pioneers Memorial to launch a 30-day Hospital Readmissions Reduction Program (HRRP) built around nurse-led outreach and guaranteed results.

Problem

Medicare readmission penalties are calculated against three years of hospital performance, so a new internal program wouldn’t show results for at least a year, while costs kept adding up. Pioneers Memorial needed a partner who could guarantee results from day one instead of betting on a multi-year internal build.

Solution

Avery placed a dedicated team of registered nurses to run outreach for every patient discharged with CHF, COPD, pneumonia, or AMI across a 30-day window and shipped monitoring devices when needed. Pioneers Memorial paid one flat fee for guaranteed results instead of taking on the cost and risk of building the program in-house.

Results

58%

Reduction in readmissions

72%

Patient participation rate among referred patients

Readmission figures reflect program performance measured against Pioneers Memorial’s own published Medicare readmission benchmarks.

How Avery Approached It

Targeted Discharge Referrals

Patients discharged with CHF, COPD, pneumonia, or AMI referred directly into the program.

Structured Nurse-Led Outreach

Ongoing outreach from Avery’s clinical team across a 30-day enrollment period.

Remote Patient Monitoring

Remote monitoring devices, including blood pressure monitors and scales, shipped to patients when applicable.

Benchmark-Based Reporting

Results tracked against the hospital’s own published readmission rates.

See How This Could Work
For Your Organization

Talk to our team about building a program like this for your organization — no cost or commitment to get started.

Talk to Our Team

URL

This field is for validation purposes and should be left unchanged.

Name:(Required)

First Last

Organization:(Required)

Organization Type(Required)

Email:(Required)

Phone: