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From hospital to home: warm handoffs are reducing readmissions

A hospital and WellMed work together to keep a close eye on patients during and after their stay

Picture of From hospital to home: warm handoffs are reducing readmissions

Dr. Ruth Adell and Dr. Kurtt Wix

What brings a 90-year-old patient to tears? Knowing someone cares about him. Such was the case for a patient of Dr. Kurtt Wix, WellMed at Central Burleson, just south of Fort Worth, Texas.

The patient was recently discharged from Texas Health Resources Huguley Hospital in Burleson after treatment for a heart condition. As he visited with Dr. Wix for his follow-up appointment, he was overcome with emotion. He had never felt such deep care and concern from his physicians, he told Dr. Wix.

What was different that moved this patient so deeply? The attention and care he received once he returned home – the result of a new WellMed warm handoff process.

How the warm handoff works

Warm handoff enhances communication among primary care providers, hospitalists and patients to ensure that once patients who are considered at high risk for hospital readmission are discharged, they continue to get the right care in the right place:

  1. When a high-risk WellMed patient is in the emergency room or admitted to Huguley, the hospital reaches out to a central contact.
  2. The patient’s primary care provider is alerted on the status of their patient.
  3. The hospitalist and PCP connect to talk about the patient’s case.
  4. The PCP brings the patient in for a seven-day follow-up to ensure they are doing well, are clear on discharge instructions, have their medications, and have everything they need to continue their recovery.
  5. The PCP also can start coordinating any transition care like home health or palliative services.

Dr. Wix said while a patient’s chart and history give providers plenty of information, warm handoff allows PCPs and hospitalists the easy opportunity to provide each other more context and to share the “twists and turns” they’ve seen in a patient’s situation.

“Typically, I would not have that conversation with the hospitalist,” Dr. Wix said. “Since this program has been in place, we’re encouraged to do that. Now we’re seeing the positive results that come out of those calls.”

How warm handoff reduces unnecessary hospitalizations

Dr. Ruth Adell, medical director for WellMed’s Houston-North Texas market, developed the warm handoff program with a Huguley staff member in May 2024. The goal of Dr. Adell, also on staff at Huguley was to find a mutual solution to reducing readmissions.

The positive effects were immediate: Readmission rates of WellMed patients in Johnson County went from more than 25% in April 2024 to below 20% in May. By September, they were below 10%.

For further proof, because of a leadership change at the hospital, the program had a brief pause – so readmission rates shot up to about 25% in November 2024. They then fell back to their previous levels the next month, after it was reinstated.

News of that success spread to other Texas Health Resources hospitals, Dr. Adell said. In February 2025, WellMed launched the warm handoff process with THR’s Arlington Memorial Hospital.

Dr. Wix said one of the biggest benefits of the warm handoff is how patients feel assured and confident they are getting the best care.

Talking about his patient and his tears of joy, Dr. Wix said: “He has an understanding that I care about him, but also knows I follow him. He’s more inclined to do what we want him to do so he doesn’t have to go back to the hospital.”