Since the introduction of CMS readmissions penalties many HCOs have focused on preventing hospital readmissions. As a result, the national rate of CMS readmissions fell from 19.5% in 2011 to 18.5% in 2013–a little more than a 5% reduction, but still a long way from the CMS goal of reducing preventable hospital readmissions by 20%. In fact, according to a recent HIN survey, while 66% of the respondents reported having a care transitions program in place, a significant percentage of these approaches failed to: Engage patients and caregivers in proper post-discharge care; Communicate a complete picture of patients’ health status to their PCPs

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