In hospital boardrooms across America, the “30-day readmission rate” is treated as a financial vital sign. It determines reimbursement levels under the Hospital Readmissions Reduction Program (HRRP); it influences star ratings; and increasingly, under new Department of Justice scrutiny, it serves as a barometer for potential “substandard care” investigations.

Yet, despite decades of regulation and millions spent on discharge planning software, the needle on preventable readmissions barely moves.

The industry is failing to solve this problem because we are misdiagnosing the root cause. We do not have a “readmission problem.” We have a “patient carryover crisis.”

The economics of the “nod”

The current standard for discharge compliance is built on a fragile assumption: That “delivery of information” equals “acquisition of skill.”

In a typical skilled nursing facility (SNF) or hospital, a nurse reviews a complex care plan with a patient. The nurse asks, “Do you understand?” The patient, anxious, eager to leave, and deferential to authority, nods yes. The nurse checks a box in the electronic medical record (EMR) labeled “patient verbalized understanding.”

Compliance is achieved. The claim is billed.

But physiologically and cognitively, that patient is often leaving the facility with a loaded weapon. They possess the instructions for their care but not the competency to execute it.

When that patient returns to the ER five days later with a septic wound or a hypoglycemic event, the system logs it as a “failed discharge.” In reality, it was a failure of carryover. The clinical investment made during the stay—thousands of dollars in surgery, therapy, and medication—evaporated the moment the patient crossed the threshold, simply because the bridge to home was built on paper rather than verified capability.

From documenting intent to auditing competency

As the Centers for Medicare & Medicaid Services (CMS) tightens the screws on value-based purchasing, the facilities that survive will be those that undergo a fundamental operational shift. We must move from an era of documenting intent (proving we taught the patient) to an era of auditing competency (proving the patient learned).

This is not a soft skill; it is rigorous risk management.

In my work analyzing post-acute workflows, I have found that “patient education” is often treated as a passive administrative hurdle. True risk mitigation requires implementing a competency operating system, a rigorous framework that treats patient understanding with the same precision we apply to clinical sterility.

We cannot assume a patient can manage a diuretic regimen because we handed them a pamphlet. We must verify their cognitive logic using auditable data points. We cannot assume a stroke survivor can transfer safely to a toilet because we told them how. We must validate the mechanics before they leave our care.

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

The regulatory storm on the horizon

The stakes for this shift are escalating. Recent signals from the DOJ indicate a widening definition of “grossly substandard care” under the False Claims Act. A pattern of readmissions is no longer just a reimbursement nuisance; it is being reframed as a failure to provide essential services.

This regulatory pivot exposes the vulnerability of the current “checkbox” approach to discharge. If a facility cannot prove that they verified a patient’s ability to care for themselves, they are defenseless against allegations that the care was effectively worthless.

Closing the gap

Solving the patient carryover crisis does not require new medical breakthroughs. It requires operational discipline. It demands that we engineer workflows where discharge is gated not by the clock, but by verifiable data.

For policymakers and payers, this is the missing variable in the readmission equation. We can penalize hospitals forever, but until we mandate and reimburse for verified patient competency rather than just patient education, we will continue to pay billions for the revolving door of the American health care system.

We have the technology to save lives. Now, we must develop the discipline to ensure those lives stay saved once they drive away.

Rafiat Banwo is a health care operational and transformational leader, visioneer, and the founder of the CATALYST Network, an initiative dedicated to addressing what she has coined the Patient Carryover Crisis. Her work focuses on reducing avoidable patient readmissions that create clinical risk and financial penalties for skilled nursing facilities and hospitals through health literacy, workflow engineering, and post-acute care redesign.

With extensive experience across nursing homes, home health care, and hospital systems, Dr. Banwo leads the CATALYST Network in delivering readmission reduction strategies, competency verification, and operational alignment for the post-acute sector. Her approach integrates frontline workflow optimization with system-level transformation to improve transitions of care and patient outcomes.

Dr. Banwo shares professional insights and engages with health care leaders through LinkedIn and through the CATALYST Network platform at catalystnetworkconsults.com.