Guide to Preventing Readmissions among Racially and Ethnically Diverse Medicare Beneficiaries

The Centers for Medicare & Medicaid Services have authored a publication devoted to readmissions reduction in diverse populations: “Guide to Preventing Readmissions among Racially and Ethnically Diverse Medicare Beneficiaries.” As minority populations have been shown to be more likely to be readmitted within 30 days of discharge and as health care systems now care for a growing racially and ethnically diverse patient population, the authors note that attending to issues specific to these populations is of the utmost importance.

CMS urges health systems and providers to employ multi-faceted approaches (that is, approaches that address multiple rather than discrete issues) as this has shown to be most effective.

Three of the eight key issues identified for particular focus:

• To address the lower rate of follow up uptake among minority populations: provide early discharge planning and structured follow up for your high-risk patients and educate them on the importance of this continued care to their future well-being.
• To address comorbidities: approach each patient as more than a single disease state, make appropriate specialist referrals and employ the multidisciplinary teams necessary to treat all of a patient’s conditions.
• To address anxiety and depression, which affect minority populations at a higher rate: screen patients and support their search for culturally-appropriate treatments and supports.

The authors recommend providers concentrate efforts in several global areas to reduce readmissions in diverse populations:

• Sharpen your data collection and risk assessment capabilities in order to better identify those patients likely to be readmitted. These should include demographic variables such as race and ethnicity as well as other socioeconomic variables such as access to care.
• Work to identify root causes. What is really responsible for any undesirable patient outcomes? (Read our PRAXIS Nexus post for more information on root cause analysis.)
• Be proactive in your readmissions reduction efforts, working to address risk before admission or as soon as possible during the patient stay.
• Employ multidisciplinary teams, both within and across settings.
• Apply a simultaneous two-prong approach: examine the social aspects that contribute to diverse populations’ higher readmissions rates while also building systems that are attentive to their specific needs.
• Be sure your teams are skilled at using culturally-competent and sensitive communications that ensure the patient understands her disease, course of care and discharge instructions.
• Build or strengthen community partnerships that will support these patients to achieving optimal health outcomes.

Three case studies, demonstrating the effective use of these approaches, are included for consideration. Of great interest to the PRAXIS community member will be the section on racial and ethnic disparities within the COPD patient community (page 19); particular attention must be paid to the needs of the African-American COPD community, readmitted at a greater rate than any other racial group.