# The 6 Preventable Gaps Driving 30-Day Readmissions (Ethan Guerrieri) Page: https://stenobird.com/podcast/home-care-strategy-lab-7276600/the-6-preventable-gaps-driving-30-day-readmissions-ethan-guerrieri Text version: https://stenobird.com/podcast/home-care-strategy-lab-7276600/the-6-preventable-gaps-driving-30-day-readmissions-ethan-guerrieri.md Podcast: [Home Care Strategy Lab](https://stenobird.com/podcast/home-care-strategy-lab-7276600) Published: 2026-04-21T12:00:00+00:00 Episode link: https://share.transistor.fm/s/994a0f4a Audio file: https://media.transistor.fm/994a0f4a/c25b7065.mp3 Processing state: not_requested JSON: https://stenobird.com/v1/public/podcasts/home-care-strategy-lab-7276600/episodes/the-6-preventable-gaps-driving-30-day-readmissions-ethan-guerrieri Duration seconds: 3514 ## Resource #57 The federal government invested $500 million to understand why seniors are readmitted to the hospital within 30 days—and uncovered six key “preventable” gaps driving the problem. Ethan Guerrieri, VP of Operations at Preferred Care at Home, breaks down the research, explains each gap, and shares how his team turned these insights into their Smooth Transition Care Program. Designed for hospitals and SNFs, this evidence-based approach equips case managers and discharge planners with the tools and education they need to reduce readmissions—and shows why home care is the missing link in keeping clients safely at home. Ethan Guerrieri Preferred Care at Home Smooth Transition Care BROCHURE Smooth Transition Care FLYER Smooth Transition Care PERSONAL HEALTH RECORD Sponsors : GUIDE-Ready Respite Provider Program (Debbie Miller + Harmonic Health) CMS GUIDE Participant List (spreadsheet download) ## Actions - request_transcript: `POST https://stenobird.com/v1/public/podcasts/home-care-strategy-lab-7276600/episodes/the-6-preventable-gaps-driving-30-day-readmissions-ethan-guerrieri/transcription-requests` — Idempotently request low-priority transcript generation for this episode. - read_markdown: `GET https://stenobird.com/podcast/home-care-strategy-lab-7276600/the-6-preventable-gaps-driving-30-day-readmissions-ethan-guerrieri.md` — Read the agent-friendly Markdown representation of this episode resource. A page view does not enqueue transcription. Agents should invoke `request_transcript` explicitly when they need this episode processed. ## Transcript Full transcripts are not published on public pages unless there is a clear rights basis.