Reducing Readmissions and Elevating Post Acute Care with The Moxie Health Group

In today’s healthcare landscape the transition from hospital to post-acute care stands as a pivotal moment for patients, their families and the broader system. 

The Moxie Health Group is committed to restoring health with dignity to every individual, reducing unnecessary readmissions and elevating the quality of care after discharge.

The challenge of readmissions

Readmissions happen when a patient is hospitalized again soon after discharge, typically within 30 days, revealing challenges in post-acute care and recovery support. 

In the United States, the 30-day all-cause hospital readmission rate remained at approximately 13.9 readmissions per 100 index admissions from 2016 through 2020. Among patients aged 21-64 whose expected payer was Medicare, the readmission rate reached 21.4 per 100 index admissions in 2020.

Hospital readmissions pose not only a risk to patient recovery but also a financial burden. According to research by AHRQ, the cost of readmissions was substantially higher compared to initial admissions. 

These statistics underscore the critical opportunity that exists to improve transitions of care and outcomes. Guided by research and clinical experience, The Moxie Health Group applies the following foundational practices to restore health and reduce readmissions.

Source: Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project (HCUP), Nationwide Readmissions Database (NRD), 2016-2020.

1. Robust discharge planning and transition coordination

Effective care transitions begin early, so discharge planning must be integrated and proactive. For example the CMS discharge planning requirements emphasise timely evaluation of post-hospital services and access for the patient, according to QIN-QIO.

2. Patient-centered community integration 

Supporting recovery within a community setting promotes rehabilitation, ensures safety, and effectively mitigates the risk of complications.

3. Linking clinical and social factors

Social determinants such as housing stability, transportation access and socioeconomic status impact readmission risk. Providers must incorporate these factors into care plans, CMS said.

4. Timely follow-up and monitoring

Deploying follow-up visits or tele-health check-ins shortly after discharge helps detect issues early before they escalate and lead to readmission.

5. Data-driven measurement and quality improvement

Tracking metrics such as readmission rates by payer age group and discharge setting enables targeted interventions and continuous improvement

Our approach

At The Moxie Health Group we implement these foundational practices through a coordinated multidisciplinary model.

• We partner with acute-care facilities to embed transition liaisons who initiate discharge planning and bridge to post-acute care.

• We maintain a network of outpatient rehabilitation providers and community-based supports to deliver seamless care after discharge.

• We use analytics to identify patients at high risk for readmission based on both clinical and social risk factors and assign enhanced coordination resources.

• We incorporate patient education and caregiver support to ensure clarity around medications, self-care responsibilities and follow-up appointments.

• We track outcomes rigorously focusing on readmission reduction, patient satisfaction functional recovery and cost containment.

By restoring health, reducing avoidable readmissions, and elevating post-acute care, The Moxie Health Group generates value across the continuum. For patients, this means better recovery, fewer disruptions from unplanned hospital returns, and stronger functional independence. For provider networks, it leads to optimized capacity, improved operational efficiency, and greater alignment with value-based care performance. For payers and the broader ecosystem, it delivers lower costs, stronger quality metrics, and closer alignment with regulatory and value-based care goals.

Why it matters

With payment and regulatory models continuing to shift toward value-based care the importance of high-performing post-acute care transitions is increasing. For instance the 30-day readmission rate across Medicare beneficiaries was reported at 14.7 percent, with disparities by setting and demographic factors.

MoxieLink, a HIPAA-compliant digital platform that unifies patient records, uses AI-powered transcription, analytics and automated coding validation to optimize workflow for healthcare providers.

The Moxie Health Group remains committed to innovation including leveraging technology, like MoxieLink, predictive analytics and deeper community partnerships to meet the evolving challenge.

Restoring health, reducing readmissions and elevating post-acute care are intertwined aims that demand strategic focus across hospital discharge transitions, home or facility-based care and community support. 

Learn more about how evidence-based strategies from The Moxie Health Group are restoring health, reducing readmissions, and elevating post-acute care nationwide here.