When the mother of a leader at Ochsner Health was discharged from one of the system’s hospitals, orders for her follow-up appointments were placed in her medical record, but the plan wasn’t clearly explained to the patient. That single experience became the catalyst for a system-wide strategy now driving Ochsner Health acute home care readmissions reduction across the New Orleans-based nonprofit health system.
The Coordination Gap Behind This Ochsner Health Acute Home Care Readmissions Strategy
“She was discharged with implied instruction to set up her own appointments,” said Beau Raymond, MD, chief medical officer for population health at Ochsner Health. “She didn’t know what she was supposed to do.” Dr. Raymond recognized from that experience that Ochsner must proactively make sure patients being discharged are consulted about the appointments they need and ensure it is at a time when they are able to complete those visits.
Why Silos Undermined Ochsner’s Earlier Programs
“We needed to be smarter about simple care coordination activities,” Dr. Raymond said during his presentation at the 2026 AMA Insight Network Summit in Chicago. “We built great programs, but in silos, that didn’t necessarily talk to each other. So, we’ve connected them to make sure they’re actually helping with those transitions.”
The Four Integrated Programs Within This Ochsner Health Acute Home Care Readmissions Strategy
Dr. Raymond calls home-based care during the initial discharge from the hospital the single most effective method of lowering readmission rates for those at high risk, with the system’s efforts emphasizing the first 15 days after hospital discharge, which he identifies as the period of highest risk. “Most readmissions come from that first 15 days,” he said.
What Each of the Four Programs Provides
An acute care at home program includes in-home visits with registered nurses, the first within a day after discharge, along with diagnostics, IV therapy, medication titration, phone calls, and remote monitoring. A nurse practitioner at home program provides NP visits for medical management, typically up to 90 days from discharge. Ochsner’s transitions of care programs include a transitional care clinic, patient navigator text outreach, a post-discharge text messaging program, and a nurse triage hotline. Dedicated outpatient care managers identify and address unmet needs in high-risk, complex care patients.
How This Ochsner Health Acute Home Care Readmissions Model Applies to Heart Failure
Ochsner Health has focused particularly on providing these services for patients with congestive heart failure, who are at high risk for readmission. In the first 15 days after discharge, patients receive daily monitoring and home interventions as needed, such as IV diuresis and medication adjustment; if monitoring indicates an escalation in care is needed, paramedics are called to provide an assessment.
The Staged Transition Across This Program’s Timeline
After 15 days, patients transition to the NP at home program and follow-up that may include cardiology and primary care physicians. After 90 days, they move to the outpatient care management program, which may include assistance from community health workers or social workers addressing social drivers of health, along with virtual visits from primary care physicians and specialists. “By doing all those things, then it’s additive, and more impactful than episodic patient care,” Dr. Raymond said.
The Measured Results Behind This Ochsner Health Acute Home Care Readmissions Program
Ochsner Health had 293 patients with congestive heart failure in 2025 enrolled in the acute care at home program, accounting for 15% of the program’s home patients and 16% of all reutilizations. Dr. Raymond said these programs have saved thousands of bed days, reduced readmissions and ER visits, and saved thousands of dollars per patient, while also helping keep some emergency patients from needing hospital admission.
The 2026 Priorities Building on This Foundation
Improving congestive heart failure patients’ care coordination is a focus of the system’s strategic priorities for 2026, including expanding emergency department identification, automating workflows in Epic, standardizing reporting to create a single source of accurate data, and creating sustainable return-on-investment modeling.
The Payer Coverage Challenge Within This Ochsner Health Acute Home Care Readmissions Strategy
Differences in patients’ health insurance coverage add a challenge to coordinating their care, since some payers won’t cover the acute care at home program. “If they can’t go to the acute care at home program, then we want them to go to the NP at home program so somebody’s seeing them,” Dr. Raymond said.
Why This Complexity Falls on Case Managers
The variations in patients’ medical needs and coverage make it a challenge for case managers, who can’t know every payer rule and eligibility pathway. Ochsner Health is putting processes in place to make it easier for case managers to choose programs and make referrals. “The case managers located in the hospital need insight into programs available to the patients in their area—all of the options—and make it easy to know the best one,” Dr. Raymond observed. “We need to make it easy for people.”
What This Ochsner Health Acute Home Care Readmissions Strategy Means Going Forward
Given Dr. Raymond’s broader observation that most health systems can build individual programs and prove they work in isolation, Ochsner’s experience suggests the harder and more valuable work lies in connecting referral, health record, communication, and accountability structures across programs rather than treating each as a standalone initiative. Given the persistent payer coverage variation complicating case manager decision-making, other health systems replicating this model may need to invest early in clear, accessible program-eligibility guidance to avoid the same bottleneck Ochsner is now working to resolve.
What to Watch Going Forward
As Ochsner Health continues its 2026 priorities of automating Epic workflows and standardizing outcome reporting, industry observers will likely watch whether these efforts produce more precise, system-wide data on readmission reduction and cost savings tied to its congestive heart failure population specifically. Given Dr. Raymond’s broader framing that disconnected care programs remain “slivers” without integration, this Ochsner Health acute home care readmissions model may offer other health systems a practical blueprint for connecting existing but siloed home-based care programs into a single, staged continuum spanning acute discharge through long-term outpatient management.
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