Reducing Medicaid Readmission among Safety Net Hospitals

Dates: 2013-2014

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

High rates of avoidable Medicaid readmissions are particularly acute in safety net hospitals, which serve some of the nation’s most vulnerable populations—the homeless, and persons with serious mental illness and substance abuse problems, HIV, and severe physical disabilities. Reducing avoidable readmissions represents an important opportunity for improving quality while simultaneously reducing the costs of providing care to Medicaid beneficiaries. With the evolving health care environment, particularly the massive expansion of Medicaid eligibility, hospitals are pushed to expand their efforts to improve transitional care for all patients, including Medicaid beneficiaries.

JSI was awarded a contract under the Agency for Healthcare Research and Quality’s (AHRQ) ACTION II Network to adapt and test best practices to reduce Medicaid readmissions among safety net hospitals.

JSI partnered with state Medicaid agencies and safety net hospitals in seven states to adapt and test current best practices for improving care transitions in this population. JSI analyzed the causes of Medicaid readmissions on a hospital specific basis, and then adapted and tested care transition strategies to address these specific drivers in safety net hospitals.

Based on this research, JSI developed a compilation of best practices to reduce Medicaid readmissions. JSI created the Hospital Guide to Reducing Medicaid Readmissions, which 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.

This guide is the only federal transitional care tool that is tailored to the adult Medicaid population. It adds significantly to the national dialogue and knowledge base around Medicaid readmissions, and provides a major stepping stone for the successful implementation of Medicaid readmission reduction strategies in hospitals across the country.


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