Reuniting Patients with Familiar Faces: Ensure Continuity of Care with Hospital Readmission Reduction Programs

A patient returns to the hospital just five days after discharge. Do they go back to the doctor who discharged them—or a new provider with no history? 

While it’s common for hospital medicine teams to ensure continuity during a patient’s visit, what about when the patient returns within a 30-day period?  

Hospital teams often struggle with readmission assignments, where there’s no clear rule for continuity and patients fall through the cracks—clinically, operationally, and relationally.  

With readmissions under scrutiny by both payers and patients, more systems are exploring how thoughtful assignment logic can improve continuity of care for readmissions. This has a few benefits: 

• It helps patients receive better care from a provider that knows their recent history 

• It helps a hospitalist’s workload since they are rounding on a patient they’re familiar with rather than obtaining H&P again. 

It’s time to reframe continuity rules to consider continuity beyond just one hospital stay – but consider how to maintain continuity for patients when they are re-admitted. Here’s a look at how you can do that with hospital readmission reduction programs. 

 

Why Continuity of Care for Hospital Readmissions Matters 

Understanding hospital readmission continuity of care is a key metric for many healthcare operational leaders. They want to understand:  

• Why did the patient get readmitted? Was it avoidable? 

• Was there a component of their care that was missed the first time around?  

• Why did their condition worsen?  

• How can we take care of them and discharge them quickly and efficiently?  

Continuity of care can improve outcomes and reduce costs. In hospital medicine, hospitalists sometimes function like a primary care provider during admissions, and when patients reconnect with the same hospitalist on readmission, it may strengthen trust and care coordination. This continuity is increasingly recognized as a marker of quality in readmission metrics. 

Readmissions also impact reimbursements, as some payors like Medicare may penalize based on readmissions. In fact, under the Hospital Readmissions Reduction Program (HRRP), hospitals with higher-than-expected 30‑day readmission rates face financial penalties on all Medicare inpatient payments, not just the immediately related admission. Penalties can reach up to 3% of a hospital’s Medicare reimbursements. Some private insurers treat readmissions as “never events” and may deny payment or combine the readmission with the original admission into a single claim.  

 

How We Handle Readmission Continuity of Care in Assign  

Healthcare organizations who are using Assign, our patient assignment process, to manage their morning assignment process, can put into place rules that automatically assign a readmitted patient to the last hospitalist they saw when they were at the hospital.  

This type of logic that routes readmitted patients back to the last attending or discharging physician, treating them almost like a patient’s PCP for their hospital stay. 

This reduces handoff gaps, builds rapport, and allows for quicker clinical insight into why the patient returned—ultimately helping physicians close the loop faster.  

In this case of a readmitted patient who was previously in the hospital during the last 30 days, instead of defaulting to geographic or shift-based assignment, systems assign the readmitted patient to their prior provider, unless unit or role constraints override.  

Recently implemented at one of our customers, Baptist Health of South Florida, the continuity-based rule has gained positive traction across sites, with teams valuing the clarity it brings to reassignments. This type of hospital readmission reduction program can drastically help improve continuity of care for patients – and improve provider satisfaction. 

 

4 Criteria to Consider When Implementing Continuity of Care for Readmissions  

Hospital leaders should consider implementing continuity rules for readmissions and define clear logic—e.g., “seen within X days” or “same diagnosis category.” Here are some criteria to consider implementing:  

1. Timing of Readmission

• • 7-day readmissions are often viewed as more preventable and more directly tied to discharge quality (They’re seen as indicator of incomplete care transitions or premature discharge). 

• • 30-day readmissions are broader and may reflect acute medical issues. Programs may prioritize continuity for those in the earlier window. 

2. Provider Continuity

• • Some hospitals flag readmitted patients at intake to try to assign them back to the original provider or at least the same service line (the team on the schedule). This is hard to do manually, so many of our customers use Assign, our patient assignment software, to not only manage re-admissions but also assign back to the right team – which provider was working on which service line.  

3. Geography and Patient Access

• • If patients are returned to the same floor/location, continuity is easier. However, the facility will need to prioritize this continuity.  

4. System and Workflow Design

• • Without medaptus, this requires EMR alerts, scheduling workflows, and staffing flexibility to ensure that if a readmission occurs, the same clinician or team can be assigned. 

• • Some systems extend this by coordinating with post-acute care and primary care providers to maintain continuity even after discharge. We can do this automatically with our rules by looking back to previous admissions. 

 

Geography or Readmission Continuity?    

Even when continuity is desired, hospital geography and role-based rules may create conflicts—e.g., when a patient is admitted to a different unit. 

Rigid adherence to continuity without considering workload balance can frustrate teams or compromise care coordination across units. Some sites voiced hesitation about continuity rules when they conflict with geography-based logic, especially in tightly structured unit-based teams. Systems should explore layered assignment logic: start with continuity, then check for unit fit or load balancing criteria before finalizing. A rule like “return to discharging physician unless not working or outside assigned unit” creates clarity while preserving flexibility. 

 

Why Readmission Continuity is Becoming More Important   

Readmission continuity is gaining attention due to payer scrutiny (especially Medicaid/Medicare), where it’s beneficial to have the original physician re-discharge the patient. Aligning continuity with value-based care expectations improves not just clinical quality, but reimbursement clarity and system credibility. The push to return patients to the original doctor is seen as a way to ensure accurate discharge documentation and reduce unnecessary delays or confusion in follow-up care. 

Integrate continuity logic into provider assignment tools and ensure EHR handoff notes reflect prior treatment history and discharge rationale. Systems that track prior attendings and trigger continuity logic within a configurable window (e.g., 7–10 days) can support revenue and care quality goals. 

 

Final Notes on Developing Hospital Readmission Reduction Programs  

Continuity of care rules support faster, safer care during readmissions. But in order to maintain workload balancing for hospitalists, assignment logic must balance geography, workload, and continuity. Aligning continuity with value-based goals supports both patients and systems. 

How often are your readmitted patients reassigned to new faces—and what would change if that weren’t the case? 

Start by asking your team: when patients come back, are we giving them back to the doctor who knows them best?