In hospital boardrooms throughout the United States, the “30-day readmission rate” is regarded as a crucial financial indicator. It determines reimbursement amounts under the Hospital Readmissions Reduction Program (HRRP); it affects star ratings; and increasingly, under the scrutiny of the Department of Justice, it acts as a measure for potential investigations into “substandard care.”

However, after decades of regulations and substantial investments in discharge planning software, the rate of preventable readmissions shows little improvement.

The healthcare industry is failing to address this issue because we are misidentifying the core problem. It’s not a “readmission problem” we face; it’s a “patient carryover crisis.”

**The economics of the “nod”**

The existing discharge compliance standards rely on a shaky premise: That “providing information” equals “gaining skills.”

In a typical skilled nursing facility (SNF) or hospital, a nurse discusses a complicated care plan with a patient. The nurse inquires, “Do you understand?” The patient, worried, eager to leave, and compliant, nods affirmatively. The nurse then checks a box in the electronic medical record (EMR) labeled “patient verbalized understanding.”

Compliance is marked. The claim is submitted.

But physiologically and cognitively, that patient is frequently leaving the facility armed with a loaded weapon. They have received the care instructions but lack the ability to implement them.

When that patient returns to the emergency room five days later with a septic wound or experiencing a hypoglycemic incident, the system records it as a “failed discharge.” In truth, it was a failure of carryover. The clinical investments made during their stay—thousands spent on surgeries, therapy, and medications—dissipated the moment the patient exited, simply because the transition to home was based on documentation rather than verified ability.

**From documenting intent to auditing competency**

As the Centers for Medicare & Medicaid Services (CMS) increase pressure on value-based purchasing, the facilities that thrive will be the ones that undergo a fundamental shift in operations. We must transition from an era of documenting intent (demonstrating we taught the patient) to one of auditing competency (showing the patient learned).

This is not merely a soft skill; it is strict risk management.

In my analysis of post-acute workflows, I have observed that “patient education” is frequently viewed as a passive administrative task. Genuine risk mitigation requires establishing a competency operating system, a rigorous framework that treats patient understanding with the same diligence applied to clinical sterility.

We cannot assume a patient can manage a diuretic regimen simply because we gave them a pamphlet. We must confirm their cognitive reasoning using verifiable data points. We cannot assume a stroke survivor can safely transfer to a toilet simply because we instructed them. We must verify the mechanics before they depart from our care.

If a patient cannot demonstrate mastery of their care plan within the safety of the facility, discharging them is not a “transition of care”; it is merely a transfer of liability.

**The regulatory storm on the horizon**

The importance of this shift is growing. Recent indications from the DOJ suggest an expanded interpretation of “grossly substandard care” under the False Claims Act. A pattern of readmissions is no longer merely a reimbursement annoyance; it is being redefined as a failure to offer necessary services.

This regulatory shift highlights the weaknesses of the existing “checkbox” method of discharge. If a facility cannot substantiate that they confirmed a patient’s ability to care for themselves, they are vulnerable to accusations that the care provided was virtually ineffective.

**Closing the gap**

Addressing the patient carryover crisis does not necessitate new medical advancements. It requires operational rigor. It calls for us to design workflows where discharges are regulated not by time but by verifiable data.

For policymakers and payers, this is the missing factor in the readmission equation. We can penalize hospitals indefinitely, but until we require and reimburse for verified patient competency rather than just patient education, we will continue to incur billions on the revolving door of the American healthcare system.

We possess the technology to save lives. Now, we must cultivate the discipline to ensure those lives remain saved once they leave.

*Rafiat Banwo is a leader in health care operations and transformation, a visionary, and the founder of the CATALYST Network, an initiative focused on addressing what she has termed the Patient Carryover Crisis. Her efforts aim to decrease avoidable patient readmissions that pose clinical risks and financial penalties for skilled nursing facilities and hospitals through health literacy, workflow engineering, and redesigning post-acute care.*

*With ample experience spanning nursing homes, home health care, and hospital systems, Dr. Banwo guides the CATALYST Network in implementing strategies for reducing readmissions, verifying competency, and aligning operations in the post-acute sector. Her strategy combines optimizing frontline workflows with system-wide transformation to enhance transitions of care and patient outcomes.*

*Dr. Banwo shares her professional insights and engages with the healthcare community.*