Hospital leaders face growing pressure to reduce avoidable readmissions while improving patient outcomes and controlling episode costs. Under value-based care models, including the Transforming Episode Accountability Model (TEAM), which began on January 1st, even modest increases in postoperative readmissions can materially impact quality scores, episode costs, and patient satisfaction; for example, research shows that a readmission following total knee arthroplasty can cost more than $10,000, representing a significant proportion of total episode expenditure.
Recent learnings from a real-world Force Therapeutics care partner–a large hospital system in the Eastern US–underscore an important truth: readmissions are not random. When organizations effectively leverage patient-reported outcome measures (PROMs) and timely patient surveys, clear patterns emerge, enabling organizations to take action before a preventable readmission can take place.
In this case, Force Therapeutics’ clinical experts analyzed rising readmission trends among total joint arthroplasty (TJA) and lumbar fusion patients within the health system. The team identified early indicators that were contributing to readmissions and proactively implemented targeted protocol optimizations. These changes improved patient recovery and outcomes while reducing unnecessary costs.
The Devil Is In The Data
When the health system’s data revealed an increase in readmissions over several months, relative to previous years, care teams didn’t have to respond with blanket changes or additional staffing. Instead, the organization turned to what it already had: extensive real-time patient-reported data.
The Force Therapeutics clinical support team conducted a comprehensive review of PROMs and discharge questionnaires completed by patients within the platform. These insights allowed the team to categorize readmissions into two distinct groups:
- Preventable readmissions, including:
- Infection symptoms
- Unmanaged or escalating pain
- Falls or injury during recovery
- Blood clots
- Constipation-related complications
- Wound concerns
- System or care access issues
- Non-preventable readmissions, such as unrelated medical events or unavoidable clinical complications
By isolating preventable drivers, the care team could focus interventions where digital care pathways and patient education can have the greatest impact.
From PROMs To Solutions
Once these patterns were identified, Force’s clinical support team translated those insights into protocol-level optimizations within the platform, ensuring patient education directly addressed the risks most likely to drive readmissions before they escalated into serious events.
New timely educational content was added to care plans associated with elevated readmission rates, reinforcing evidence-based education in areas known to reduce complications, including blood clot prevention, constipation prevention, swelling and bruising management, fall prevention, and relaxation and non-pharmacologic techniques for pain management.
As additional trends surfaced in the PROMs data, such as reports of urinary tract infections (UTIs) and pneumonia, the Force clinical support team rapidly built and deployed new educational content focused on prevention strategies and early warning signs.
Because Force Therapeutics’ protocols are dynamic and customizable, these updates were implemented without disrupting existing clinical workflows, ensuring patients received timely, relevant guidance aligned to their risk profile, procedure, and recovery phase.
The Right Information At The Right Time
PROMs and discharge questionnaires also highlighted a patient issue driving unnecessary utilization: uncertainty.
Some patients sought emergency care for concerns that could have been resolved with earlier education or direct communication with the care team. To address this, Force reviewed and optimized automated patient emails and in-app care instructions to clearly explain:
- Which symptoms warrant a call to the clinic
- What can safely be managed at home
- When emergency care is appropriate
Critically, this guidance was set to be delivered earlier in the recovery journey, before anxiety and uncertainty escalated. With clearer expectations and decision support, the potential for unnecessary ED visits was reduced, and inbound clinic phone calls became unnecessary because patients already had the information they needed, effectively improving efficiency while also enhancing the patient experience.
Education as Proactive Intervention
Education is foundational in optimizing patient outcomes, but pairing it with remote monitoring creates an even stronger safety net. For this patient population, the Force team enabled alerts for patients reporting higher-than-expected postoperative pain. When triggered, the care team automatically receives a notification and can message the patient directly within the platform to check in on progress, reinforce pain-management strategies, and adjust recommendations or escalate care if needed.
This allows clinicians to intervene early before pain becomes a driver of avoidable readmission or unscheduled care.
Moreover, two additional automated check-in points were deployed to address common, preventable complications:
- Constipation monitoring, with immediate education delivered if symptoms are reported
- Wound and incision check-ins, triggering best-practice wound care guidance ahead of when patients typically reported wound issues
These touchpoints ensure patients do not fall through the cracks and are receiving the information they need, while still minimizing additional workload for care teams operating above capacity.
Preoperative Optimization for Postoperative Success
To maximize the impact of post-discharge improvements, Force experts extended their recommendations upstream, focusing on discharge planning and increasing discharge to home.
By analyzing the discharge questionnaire data, the Force clinical team determined that, while less than 3% of the health system’s patients were being discharged to SNFs or IRFs, the primary reasons justifying these discharges revolved around physical barriers to recovery at home, such as navigating stairs, bathrooms, and bedroom set ups.
Subsequently, Force recommended leveraging the Risk Assessment and Prediction Tool (RAPT) for TJA patients to better predict discharge location. Based on RAPT responses and clinical risk factors, Force automatically assigned risk tags (high, medium, low) and created a watchlist for high-risk patients. This watchlist now proactively alerts the care team, enabling earlier planning around mobility needs, home support, and patient education and helping achieve reduced reliance on SNFs or IRFs and lowering downstream risk for safe at-home recovery.
Custom questionnaires were also added to assess critical home environment risk factors preoperatively. Addressing these considerations before surgery empowers care teams to set expectations, tailor education, and prevent discharge challenges that can later contribute to readmissions.
Why PROMs and Patient Education Matter More Than Ever
This real-world example highlights a core principle of modern care delivery: PROMs are more than just a reporting requirement or a survey. When paired with clinically validated patient education, automated workflows, ongoing clinical support, and proactive care team engagement, they become a powerful engine for quality improvement.
As hospitals prepare for increased accountability across the surgical episode as part of value-based care mandates, strategies like these are essential to delivering high-quality, cost-effective care at scale.
Learn how Force Therapeutics can help you reduce readmissions and optimize surgical episodes through PROMs-driven insights and patient education:
