Stronger Transitions. Healthier Communities. Fewer Readmissions.
Recent CMS data shows that readmissions remain a significant challenge for hospitals nationwide. As highlighted in Modern Healthcare’s recent article, “CMS releases hospital readmission penalties for 2027,” many hospitals will continue to face Medicare reimbursement reductions under the Hospital Readmissions Reduction Program (HRRP), reinforcing the importance of effective transition-of-care strategies.
Hospitals are working every day to improve outcomes, manage costs, and help patients recover safely after discharge. Yet even the strongest discharge plan can fall short when patients encounter medication questions, transportation challenges, limited caregiver support, or difficulty accessing follow-up care at home.
The challenge is clear. Nearly one in five Medicare patients are readmitted within 30 days of discharge, and hospitals with excess readmissions may face Medicare reimbursement reductions through the Hospital Readmissions Reduction Program (HRRP). CMS payment reductions can reach up to 3% of Medicare inpatient payments, making readmissions both a clinical and financial concern.
Reducing avoidable readmissions requires a collaborative approach—one that connects hospital care teams, community resources, and patients with timely support beyond the hospital walls.
Supporting Recovery Beyond Discharge
The transition home can be one of the most vulnerable points in a patient’s care journey. Medication confusion, missed appointments, transportation barriers, limited caregiver support, and unmet social needs can quickly put recovery at risk and create added strain for families, care teams, and community resources.
Follow-up calls can help identify concerns, but some patients need a more connected level of clinical and community-based support to resolve issues before they escalate.
That is where proactive, patient-centered engagement can make a meaningful difference.
Meet ODV Guide℠
ODV Guide℠ is an OnDemand Visit transitions-of-care solution designed to help hospitals support patients during the critical post-discharge period. By bringing together in-home visits, telehealth, care coordination, and connections to social support services, ODV Guide℠ helps extend the hospital’s care plan into the home and address barriers that could otherwise lead to an avoidable return.
The result is a more connected discharge-to-doorstep experience that supports patients, strengthens collaboration with hospital care teams, and helps communities make better use of available healthcare resources.
The ODV Guide℠ Program has proven results with significant reductions in Medicare and Medicaid readmissions. We can help! Learn how we have deployed unique engagement techniques to reach and engage a higher percentage of high risk patients, explain and manage to their discharge plan, and secure the resources necessary for the patient to stay home and avoid re-hospitalization.
Interested in setting up a meeting? Connect with us by emailing svincent@priorityondemand.com or visit us at ondemandvisit.com.