Effective healthcare is more than just diagnosing illnesses and prescribing treatments—it’s about ensuring those treatments are managed well once the patient leaves the hospital. At First Point MD, we understand that poor medication management is a major driver of hospital readmissions, costing lives, resources, and quality of care. In this article, we dive deeply into how medication mismanagement leads to readmissions, examine key risk factors, and outline how patients, families, and healthcare providers can work together to prevent avoidable return hospitalizations.

Why Hospital Readmissions Matter

Hospital readmissions—especially within 30 days of discharge—are a critical measure of healthcare quality and effectiveness. According to the Centers for Medicare & Medicaid Services (CMS), readmission rates carry financial penalties for hospitals under the Hospital Readmissions Reduction Program (HRRP). 
From a clinical standpoint, readmissions signal unresolved issues in the transition of care: inadequate discharge planning, poor patient understanding, and perhaps most importantly, medication‐related problems (MRPs).

Research indicates that around 20% of hospital readmissions are related to medications and that a substantial fraction of those are potentially preventable. Addressing medication management is thus not a peripheral issue—it’s central to safe, high‐quality care.

What Is Poor Medication Management?

Poor medication management refers to the breakdowns that occur around the use of medicines. These breakdowns can include:

• Incomplete or incorrect medication reconciliation at admission or discharge

• Lack of patient understanding about their medication regimen (how/when to take, why it’s needed)

• Non‐adherence (not filling prescriptions, skipping doses, stopping early)

• Polypharmacy (many medications, increasing risk of interactions and errors)

• Changes to medications without adequate follow-up

• Communication gaps between hospital, outpatient, pharmacy, caregiver, and patient

Each of these creates risk. For example, one detailed study found that older adults discharged with medication changes were more likely to be readmitted due to medication‐related causes. Another review highlighted that of the readmissions examined, 69% of medication‐related readmissions were potentially preventable.

How Poor Medication Management Leads to Readmissions

Let’s go through the chain of events by which medication mismanagement often culminates in a return to hospital care.

Discharge Without Clear Medication Plan

When patients leave the hospital, they often are given new prescriptions, dosage adjustments, or discontinued medications. If these changes are not clearly communicated—or the patient doesn’t understand—the risk of error rises.
One study found that patients whose medications were adjusted at discharge had higher odds of medication‐related readmissions.

Errors or Misunderstandings at Home

Without support, patients might:

• Take the wrong dose

• Mix up medications

• Continue old medications that should have stopped

• Fail to fill new prescriptions

• Experience side effects they don’t recognize and stop meds

In cases of polypharmacy, this becomes even more risky.

Lack of Follow‐Up and Support

After discharge, patients may not have easy access to a pharmacist or clinician to answer questions. Care transitions are often weak: communication between hospital teams, primary care, and pharmacies may be fragmented. This is a key factor identified in many readmission studies.

Adverse Outcomes Triggering Readmission

The result can be an adverse drug event (ADE), uncontrolled condition (e.g., hypertension, diabetes), or complication (e.g., fluid overload in heart failure). These escalate into conditions requiring urgent care or rehospitalization. Studies show that medication‐related problems account for a significant share of preventable readmissions.

The Vicious Cycle of Readmissions

Once a patient is readmitted, the risk of further problems increases: more medications may be added, the patient becomes weaker, coordination becomes harder, and the cost of care rises both financially and for patient quality of life.

Key Risk Factors for Medication-Related Readmissions

Some patients are more vulnerable than others. Recognizing these risk factors helps target interventions.

• Older age – age‐related changes in metabolism and multiple comorbidities increase risk.

• Polypharmacy – use of multiple medications increases complexity and the chance of interactions or errors.

• Medication changes at discharge – adjustments or additions at the point of leaving hospital raise risk.

• Living alone or lacking support – patients returning to home without caregiver support are more likely to mismanage meds.

• Poor communication / inadequate documentation – if discharge summaries, medication lists, or outpatient communication are incomplete, risk rises.

• Chronic illnesses with complex treatments – conditions like heart failure, COPD, renal disease demand many medications and careful monitoring.

Strategies for Effective Medication Management

Given the stakes, what can patients and healthcare systems do? At First Point MD, we emphasize a multi‐pronged approach.

Robust Medication Reconciliation at Every Transition

At admission, transfer, and especially discharge, a full review of all medications (what the patient was taking, what’s added, stopped, changed) is essential. This ensures consistency and avoids omissions or duplications. The NEHI report highlights this as a foundational step.

Clear, Patient‐Friendly Medication Instructions

Patients should receive a written list: medication name, purpose, dose, time, and any specific instructions (e.g., with food, avoid alcohol, monitor blood sugar). Plain language matters.

Involve Pharmacists and Care Coordinators

Studies show that pharmacist‐led interventions reduce readmissions. For example, a recent pharmacist‐led study found readmission rates of 10% vs 22% when pharmacists intervened in elderly patients’ discharge care.

Ensure Follow-Up After Discharge

Within days of discharge, patients should have follow‐up contact (phone or in‐person) to check on how medications are going, answer questions, clarify issues. Proactive check‐ins can catch problems early.

Simplify Medication Regimens Where Possible

Reducing complexity helps: fewer pills, fewer times per day, using combination drugs when safe. Deprescribing unnecessary meds, when appropriate, can reduce risk.

Patient Education and Engagement

Educate patients on why each medication matters, what side effects to watch for, what to do if they miss a dose. Encourage them to keep a medication list and bring it to every appointment.

Use Technology and Reminders

Apps, pill boxes, alarm reminders, and automated refills help improve adherence. These tools reduce the chance of forgetfulness—a common root cause of readmissions.

Communicate Across the Continuum of Care

Hospitals, primary care physicians, home health, pharmacies and caregivers must share information. Discharge summaries with updated medication lists must be promptly sent. The lack of communication is a key failure point.

Role of First Point MD in Preventing Readmissions

At First Point MD, our model is rooted in preventive, coordinated care with a strong focus on medication management:

• Comprehensive discharge planning: Before patients leave hospital, our team reviews medications, simplifies regimens, and puts follow‐up in place.

• Medication review and reconciliation: Our clinical pharmacists collaborate with physicians to ensure medications are accurate, necessary, and safe.

• Post‐discharge support: We schedule timely follow‐up calls or visits, monitor adherence, and address concerns early.

• Patient education: We provide clear documentation, teach patients to ask the right questions, and support caregiver engagement.

• Care coordination: We ensure communication between hospital, outpatient providers, pharmacy, and home health services is seamless.

By focusing on these core areas, we strive to reduce the preventable readmissions that stem from medication mismanagement.

Real-World Impact: Why This Matters

Poor medication management isn’t just a technical issue—it has real life consequences:

• For the patient: Readmissions mean more illness, discomfort, disruption, and risk of further complications.

• For families/caregivers: The burden of managing complex medications falls on them; mistakes increase stress and risk.

• For healthcare systems: Readmissions drive costs upward, strain resources, and trigger penalties under programs like HRRP.

• For quality of life: Rehospitalization affects financial, emotional, and physical well-being of patients and their families.

Reducing readmissions through improved medication management therefore benefits everyone—patients, clinicians, health systems, insurers, and society at large.

Challenges and Barriers to Better Medication Management

While we know what to do, implementation is often challenging:

• Complex patients with multiple conditions and many medications

• Fragmented care systems: hospitals, pharmacies, home health, and primary care often operate in silos

• Inadequate time or resources at discharge to ensure full patient understanding

• Patients with cognitive impairment, low health literacy, or lack of support at home

• Financial or access barriers to medications (costs, transportation, pharmacy hours)

• Variability in pharmacy coverage or medication changes that aren’t conveyed to outpatient providers

Recognizing these barriers is key to designing effective solutions.

Key Takeaways & Action Steps for Patients and Providers

For Patients & Families:

• Bring a current, comprehensive medication list to every appointment.

• Ask “What is this medication for? When should I take it? What side‐effects should I watch for?”

• Use pill boxes, alarms or apps to help you remember.

• Let your provider know if you’re having trouble with cost, side‐effects or sticking to the regimen.

• Attend your follow‐up appointment, and be honest about difficulties in managing medications.

For Healthcare Providers:

• Perform detailed medication reconciliation at every transition point.

• Simplify regimens where possible and deprescribe when safe.

• Provide patients with easy‐to‐understand medication instructions.

• Ensure follow‐up is scheduled and that a point person (pharmacist, coordinator) is assigned to monitor medication management.

• Communicate clearly with outpatient providers and pharmacies about any changes.

• Identify high‐risk patients (elderly, polypharmacy, living alone) for targeted interventions.

Conclusion

Poor medication management is not a minor oversight—it is a fundamental breakdown that leads to a high share of hospital readmissions. At First Point MD, we believe that every discharge is an opportunity to get medication management right: to ensure patients leave the hospital with clarity, support, and a care team that follows up. By addressing the risk factors, improving communication, and engaging patients and families actively, we can reduce avoidable readmissions, improve outcomes, and support a healthcare system that truly works for patients.

If you or a loved one are facing multiple medications, a recent hospitalization, or changes in treatment, reach out. At First Point MD, we are committed to helping you manage medications safely—and keeping you healthy beyond discharge.