Follow-Up Care Cuts Hospital Readmissions for Medicare Patients

A new study from UTHealth Houston School of Public Health finds that timely follow-up care after hospital discharge can significantly reduce the likelihood of hospital readmission. yet many high-risk Medicare patients never receive follow-up care. 

Published in The American Journal of Managed Care, the study, led by Maria Ukhanova, MD, PhD, assistant professor in the Department of Management, Policy and Community Health at the School of Public Health, examined more than 579,000 hospital admissions using national Medicare data to better understand how complex medication use and post-discharge care affect 30-day readmission rates. 

“Our study shows that the period immediately after hospital discharge is a critical opportunity to improve patient outcomes,” Ukhanova said. 

Patients taking 10 or more medications, a level known as hyperpolypharmacy, were more likely to be readmitted, particularly those with multiple chronic conditions. However, the study found that medication count alone was not the primary driver. Instead, underlying health status and prior health care use played a larger role in readmission risk. 

The clearest difference was whether patients received follow-up care after leaving the hospital. 

Across both older adults and individuals with disabilities, those who had a post-discharge visit were significantly less likely to be readmitted within 30 days. Transitional care management (TCM), which includes medication review, care coordination, and follow-up support, was associated with the greatest reduction in readmissions. 

 “While patients with a high medication burden are at greater risk, timely follow-up care can meaningfully reduce the likelihood of readmission,” Ukhanova shared. “This underscores the importance of coordinated post-discharge care and careful medication management, particularly for older adults, and even more so for younger and middle-aged adults with disabilities.” 

Despite these benefits, relatively few patients received this level of care. Among patients with complex medication regimens, approximately 15% of older adults and 11% of individuals with disabilities received TCM services after discharge. 

These numbers reflect a gap in follow-up care during a critical window after discharge. Patients at the highest risk of readmission, those managing multiple conditions and medications, may benefit the most from coordinated follow-up care, including medication reconciliation and deprescribing when appropriate. 

“When the post-discharge window is missed, patients—especially those taking many medications—face a much higher risk of returning to the hospital,” Ukhanova said. “Without timely follow-up, starting with an initial call within the first few days after discharge, issues like medication complexity can quickly escalate, leading to preventable complications and readmissions.” 

The findings show that improving access to and use of post-discharge services could play a key role in reducing avoidable hospital readmissions. The authors note that future research should examine the cost-effectiveness of expanding these services and identify which patient populations would benefit most.