Implementing and Evaluating the Hospital Guide for Reducing Medicaid Readmissions

Dates: 2014-2016

Geographic Scope: Nationwide

Client(s): Agency for Healthcare Research and Quality (AHRQ)

Services: Health Care & Public Health Planning, Training & Technical Assistance, Applied Research & Evaluation, Policy Development & Implementation

Technical Expertise: Chronic Disease Management, Health Care Reform, Integrated Care Models, Population Health, Safety Net


This project was a follow up to the Reducing Medicaid Readmissions among Safety Net Hospitals project, in which we developed a Hospital Guide for Reducing Medicaid Readmissions in partnership with AHRQ. The guide walks hospitals through data analysis, taking inventory of their current readmissions efforts, and developing a portfolio of strategies to reduce Medicaid readmissions. The guide describes how to implement three types of strategies: improving standard hospital-based transitional care, collaborating in cross-setting partnerships, and using enhanced services to help patients at highest risk of readmission. It also comes with 13 customizable tools for different stages of this process, including a Centers for Medicare & Medicaid Services (CMS)' Discharge Planning Conditions of Participation checklist.

The goal of this two-year project was to disseminate, implement, and evaluate the guide in order to increase and assess its impact on Medicaid readmissions. In this project, JSI collaborated with several partner organizations and a set of six hospitals in order to engage in these activities, and ultimately developed a replicable technical assistance program for future organizations to implement.