Readmission penalties are getting harder to avoid. For fiscal 2027, CMS is cutting Medicare payments to 2,334 hospitals, about 80% of those it evaluated, up from 78% the year before. This is also the first year the scores include Medicare Advantage patients.
The Hospital Readmissions Reduction Program scores six conditions and procedures: heart attack, heart failure, COPD, pneumonia, coronary artery bypass surgery, and elective hip or knee replacement. A hospital can be penalized for excess readmissions in just one of them.
Where readmissions start
Many readmissions trace back to the discharge itself and the first weeks at home:
- The patient leaves unsure what their diagnosis means, which medicines changed, or what warning signs to watch for.
- Instructions are rushed, written above the patient's reading level, or never checked for understanding.
- Follow-up comes late, or not at all, so a problem that was manageable on day 4 becomes an ER visit on day 10.
Nurses know what a good discharge looks like. They rarely have the time to deliver one to every patient.
A proven protocol, delivered every time
MayaRED delivers the Re-Engineered Discharge (RED) protocol, developed at Boston University and shown in trials to reduce readmissions. MayaRED implements all 13 RED components and was built with the same faculty who created it.
- At discharge: a conversational AI explains the diagnosis and medications at a 6th-grade reading level and uses teach-back to confirm the patient understood. It can happen at the bedside or after the patient gets home.
- For the next 30 days: one companion app combines two-way texting, connected devices and symptom check-ins, and each check-in produces a note for the care team.
- People in the loop: our staff supports your clinicians, so patients are reached within 48 hours and seen by their own clinician within 7 days.
Early results
In a pilot with heart failure patients, presented at AHA Scientific Sessions 2024, all 18 patients who used MayaRED said they would rather receive their discharge information from Maya than from a nurse or doctor. Preliminary 30-day readmissions were 16.6% for MayaRED patients versus 29% for 17 matched controls. The sample is small and the readmission comparison is preliminary. Read the case study.
No cost to the health system
By default, MayaMD bills transitional care management and the health system pays no fee. If your own clinicians bill, our fee comes out of the new revenue the program creates, not your current budget.
Talk to us about a MayaRED pilot.
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