Subscribe to The Podcast by KevinMD. Watch on YouTube. Catch up on old episodes!
We explore the pressing issue of hospital readmissions and their significant impact on health outcomes and financial strain within the health care system. Our guest, health care executive Ahzam Afzal, shares insights into the strategies and challenges of reducing readmission rates, including the role of data-driven care, cohesive communication, and effective care coordination. We delve into how staffing shortages affect the implementation of new CMS programs and discuss practical solutions for supporting patients post-discharge to promote better outcomes.
Ahzam Afzal is a health care executive.
He discusses the KevinMD article, “Effective strategies to reduce hospital readmissions amidst staffing shortages.”
Our presenting sponsor is DAX Copilot by Microsoft.
Do you spend more time on administrative tasks like clinical documentation than you do with patients? You’re not alone. Clinicians report spending up to two hours on administrative tasks for each hour of patient care. Microsoft is committed to helping clinicians restore the balance with DAX Copilot, an AI-powered, voice-enabled solution that automates clinical documentation and workflows.
70 percent of physicians who use DAX Copilot say it improves their work-life balance while reducing feelings of burnout and fatigue. Patients love it too! 93 percent of patients say their physician is more personable and conversational, and 75 percent of physicians say it improves patient experiences.
Help restore your work-life balance with DAX Copilot, your AI assistant for automated clinical documentation and workflows.
VISIT SPONSOR → https://aka.ms/kevinmd
SUBSCRIBE TO THE PODCAST → https://www.kevinmd.com/podcast
RECOMMENDED BY KEVINMD → https://www.kevinmd.com/recommended
GET CME FOR THIS EPISODE → https://www.kevinmd.com/cme
I’m partnering with Learner+ to offer clinicians access to an AI-powered reflective portfolio that rewards CME/CE credits from meaningful reflections. Find out more: https://www.kevinmd.com/learnerplus
Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcasts. Today, we welcome Ahzam Afzal. He’s a health care executive. Today’s KevinMD article is “Effective Strategies to Reduce Hospital Readmissions Amidst Staffing Shortages.” Ahzam, welcome to the show.
Ahzam Afzal: Thanks for having me, Kevin.
Kevin Pho: So let’s start by sharing your story and journey.
Ahzam Afzal: Yeah, so a little bit of background. So I’ve been in this value-based care world for the last decade. Initially, I started out as an executive at CVS Health, building out a lot of medication therapy management programs. The goal of that was really to design programs that were to help reduce readmissions, drive down total cost of care, and enhance medication therapy management.
I did that for a number of years, helping to really drive down the total cost of care in those specific segments. I think consistently one of the challenges in primary care, as well as in the outpatient pharmacy world, is that patients just didn’t have the resources or the reminders or the technology in place to ensure that they were compliant with their medications or adhering to their medications. We helped build out some programs doing that.
Since then, back in 2015, CMS actually rolled out a program called Chronic Care Management. That was a program designed to ensure that patients were more compliant with their medications or adhering to their medications. There was also a program designed to ensure that in between office visits, there was a system in place to check in on patients, set care goals with the patient, and ensure that they’re not essentially getting hospitalized.
Those programs launched in 2015, and then I started my first chronic care management company shortly after that. The goal of that program was to ensure that patients were more adherent to their therapies, to their treatment plans. We grew that across 18 states, serving around 60,000 unique lives.
Later, I exited that venture to Permonta, New Jersey, but through that work, I had the opportunity to work really closely with a number of different ACOs, other health systems, and CMS Innovation on a few different initiatives. The discussion points continually were that there are specific areas in health care that are areas of high cost.
One of the areas that consistently came up in terms of high cost was the post-acute care segment. The post-acute care market tends to have one of the highest areas of spend because these are the sickest of the sick, the highest acuity patients. There was a big need to ensure that these patients had the right follow-through of care through the care transitions from the point of hospital discharge through the entry point into these post-acute facilities that are in the SNFs. When they go home for that 90-day post-discharge period, it’s a very high-cost area for CMS and for the health system.
So, I started a company called Puzzle Health Care about three years ago as a result of those big issues that we identified. It was really designed to tackle this readmission problem that’s been in place now for almost a decade. The goal of that program is to ensure that patients have the right care and the right support through the transitions of care. We’ve been blessed enough to work with some of the largest health systems across the country and have been able to achieve really strong readmission rate reductions with some of our biggest health system partners, such as Health Care and Coral Health out here in Michigan.
Now, I think it’s about being able to extrapolate that more on a national scale, and that’s what we’re looking to do. I’m excited to talk further about how we can solve this problem together.
Kevin Pho: Sure. So let’s talk more about those strategies to reduce readmissions in your KevinMD article. For those of you who get a chance to read it, tell us more about it.
Ahzam Afzal: Yeah, so the article really came from years of firsthand experience observing how critical hospital readmissions are to both patient outcomes and the economics of health care. For context, hospital readmissions are costing the U.S. health system over 52 billion dollars annually. Many of these costs are concentrated in high-risk, high-cost areas like cardiology, specifically in chronic disease management, as well as post-acute transitions. The fact that nearly 15 percent of discharged patients are readmitted within 30 days underscores that there are a lot of systemic inefficiencies that persist in our system.
When writing the article, I wanted to address not just the magnitude of the problem, but also the root causes, especially in the context of staffing shortages in the post-acute space. Staffing shortages are a critical leverage point in value-based care models because these facilities manage some of the sickest and most complex patients, yet they’re often the most under-resourced and understaffed. They’re disconnected from the broader health care system, resulting in missed opportunities for interventions, poorly managed care transitions, and preventable readmissions.
I structured the article around three core strategies that I believe are foundational to solving this readmission problem. The first is data-driven care delivery. Data is the backbone of any value-based care initiative. Without actionable insights, clinicians are flying blind. Predictive analytics can help us identify patients at the highest risk for readmission—those with poorly controlled chronic conditions, multiple comorbidities, or social determinants of health that make it harder for them to recover at home. The real challenge isn’t just identifying these patients; it’s intervening in real-time.
At Puzzle Health Care, we’ve implemented real-time monitoring tools that track patient vitals in skilled nursing facilities and even at home. These tools enable us to flag early signs of deterioration, allowing care teams to step in before a patient ends up back in the emergency room. For example, in conditions like CHF, weight gain, increased shortness of breath, or abnormal blood pressure detected through monitoring technologies can lead to simple medication adjustments that prevent readmissions.
We’re leveraging various platforms, including radar sensor technology and other devices, to provide clear visibility into what patients experience when they leave the hospital and enter skilled nursing facilities. The second strategy is cohesive communication across the care continuum. This is often where the system breaks down. A patient may leave the hospital with a detailed care plan, but if the SNF staff, primary care providers, and specialists aren’t on the same page, critical details get lost. These communication gaps lead to medication errors, missed follow-up appointments, and exacerbations of conditions, all causing readmissions to skyrocket.
The goal is to ensure a streamlined and centralized EHR solution is in place between the hospital, the SNF, and during the post-discharge window. This ensures everyone has the right information to interact effectively and achieve the desired outcomes. It’s not just about the technology; it’s also about standardizing workflows. For example, when a patient transitions to an SNF, there should be a structured protocol for medication reconciliation, care plan handoffs, and follow-up schedules. These small steps make a huge difference in preventing unnecessary hospitalizations.
The third pillar, perhaps the most important, is empowering patients and caregivers. Even with perfect care coordination among providers, patients ultimately bear much of the responsibility for their recovery. Expecting them to manage complex medication regimens or follow care plans without support is unrealistic. In the article, I discuss practical solutions like leveraging digital tools to send medication reminders, offering telehealth check-ins, and providing personalized care plans that are easy to understand.
For patients discharged home, we’ve seen great success with RPM and remote patient monitoring combined with regular telehealth follow-ups. This combination ensures patients don’t feel abandoned once they leave a facility and gives providers a way to intervene proactively when something goes wrong.
Kevin Pho: So give us maybe a couple of case studies that would really chart that post-discharge course and how some of these technologies you mentioned would really move the needle. You can include my role as a primary care physician about how I would intersect with that.
Ahzam Afzal: Yeah, for sure. One case that comes to mind is when patients leave the hospital and go into an SNF for rehab, then transition home. A big challenge is ensuring patients are safe and healthy enough to handle their ADLs and return to their prior level of functioning before hospitalization.
For example, we deploy remote patient monitoring sensors—health tags typically placed on undergarments. These tags are machine washable, have a battery life of 12 months, and track heart rate, respirations, movement, and activity levels. When our care management teams reach out to a patient like Mrs. Smith post-discharge, we can notice if she hasn’t been out of bed in a couple of days or if her respirations are increasing, which could indicate an infection or deterioration.
Heart rate and respiratory rates are the two most common predictors of patient deterioration. Having this real-time information helps drive outcomes and provides care teams with the right insights. This includes not just subjective information from patients but objective data from RPM panels.
Additionally, we ensure that health system partners collaborate to provide patients with a place to go instead of getting hospitalized. OSF Health Care has been a great partner, setting up high-acuity clinics designed to manage patient exacerbations that may not warrant hospitalization. These clinics serve as referral points when issues arise, allowing us to triage whether a patient needs an observation stay or hospitalization.
In the SNF world, when patients leave the facility, if they’re within the 30-day post-discharge window, they can return to the SNF instead of being readmitted to the hospital. Skilled nursing facilities are good partners to route patients back to if issues occur. Most post-discharge cases involve patients with remote monitoring devices that transmit data back. When we identify a potential readmission, post-acute facilities can intercept before the patient goes to the hospital.
Kevin Pho: Is that fair to say?
Ahzam Afzal: Yeah, exactly. The brick-and-mortar solution involves directing patients to high-acuity clinics. Initially, the nursing team triages issues, but there’s also a telehealth component where an ER physician can enter a telehealth encounter to determine if the patient should go to a high-acuity clinic versus the hospital. Health system partners leverage their ER doctors and other providers to discuss with our care teams whether a patient should go to the clinic or the hospital. This helps us triage the level of care provided across the board.
Kevin Pho: So tell us what kind of outcomes you have. You said that you work with several large systems in Michigan. Tell us some type of outcomes data from your technology.
Ahzam Afzal: Sure. When we first started the company, our first health system partner was OSF Health Care. OSF Health Care has about 17 hospitals and is one of the largest health systems in the state of Illinois in terms of hospital accounts. When we engaged with them, they had a huge problem with readmissions, particularly for patients leaving the hospital, going into an SNF, and then going home. They tracked readmissions at about 29 percent for patients leaving SNFs who were originally coming from OSF. The issue was a lack of follow-through care after patients left the SNFs.
When we came in, it took about three or four months to fully embed in around 75 to 80 skilled nursing facilities that were part of their post-acute discharge network. After engaging with them, we were able to reduce their readmissions from 29 percent down to 9 percent within a year. Initially, they lost over a hundred million dollars in readmission penalties over the last two years. The significant savings came from the reduction in total spend in the post-acute space.
Another case is Coral Health, the largest health system in Michigan. We work with Boma, which manages the post-acute network of skilled nursing facilities for Coral Health East. They have about 50 to 60 SNFs where they discharge patients and have readmission opportunities. Their analysis showed that post-acute care consistently has one of the highest areas of spend across the country due to the high-acuity population.
After a little over a year of partnership, their results placed them in the top 5 percent in the country in terms of post-acute spend. Historically, they performed well across the board, but the post-acute area was an opportunity. By layering in our programs, ACOs and health systems can drive down the total cost of care in the post-acute segment.
Kevin Pho: Any barriers or obstacles in expanding post-discharge technology?
Ahzam Afzal: Yes. Recently, we’ve seen more adoption. Often, health systems are more innovative in their thought processes, but skilled nursing facilities are lagging behind. Operators of SNFs are often stuck in archaic ways of doing things, adhering to methods they’ve used for the last 15 or 20 years. There’s a need for change management to show SNFs the benefits of adopting new technologies and processes.
Engaging a key health system partner in a large state was crucial to get buy-in and demonstrate results. Now, many health systems are looking to add these solutions to their SNF partners. When SNFs hear it from their health system referral sources, they’re more likely to adopt these solutions to ensure their health system partners are satisfied, as it helps with the continuum of care.
The biggest obstacle is change management in this market.
Kevin Pho: We’re talking to Ahzam Afzal, a health care executive. Today’s KevinMD article is “Effective Strategies to Reduce Hospital Readmissions Amid Staffing Shortages.” Ahzam, let’s end with some take-home messages you want to leave with the KevinMD audience.
Ahzam Afzal: I think the health care system today is still too often built around processes and silos rather than the patients it’s meant to serve. My take-home message is that we need to fundamentally rethink how we approach the patient experience. It starts with asking ourselves one critical question: What does the ideal health care journey look like from the patient’s perspective?
For me, the answer is a system where every touchpoint—whether it’s a hospital, a skilled nursing facility, or a follow-up telehealth visit—feels connected, seamless, and personalized. Patients shouldn’t feel like they’re navigating a maze or falling through the cracks. Instead, they should feel supported and empowered every step of the way. To achieve this, we need to move beyond simply treating episodes of care and embrace a more longitudinal approach.
This means leveraging technology not just to predict and prevent adverse outcomes but to actively shape better patient journeys. Predictive analytics, remote patient monitoring, and AI can provide the insights needed to intervene early, reduce readmissions, and offer personalized care. However, these tools must be paired with a commitment to empathy, communication, and truly understanding what a patient is going through.
Imagine a health care system where a patient discharged from the hospital is automatically connected to a care team that spans their primary care provider, their post-acute facility, and even community resources. This entire team is equipped with real-time data and proactively reaches out to the patient—not just to check vitals, but to ask how they’re feeling, address barriers to recovery, and ensure they understand their care plan. That’s the kind of transformation we’re talking about: making the patient experience proactive, not reactive.
Ultimately, the patient experience is about trust. When patients feel cared for, know their providers are communicating, and experience smooth transitions without their concerns falling through the cracks, they’re more likely to engage in their own care across the board. Patients leaving the hospital are often in a very vulnerable state without the right supports at home or a proper setup to understand their care plan fully. For us, it’s about putting the patient first, utilizing technology and data to support them, which leads to better outcomes for health systems, skilled nursing facilities, and most importantly, for the patient.
Kevin Pho: Awesome. Thank you so much for sharing your perspective and insight. Thanks again for coming on the show.
Ahzam Afzal: Thanks, Kevin.
