Government releases first-of-its-kind toolkit to help hospitals, post-acute facilities reduce Medicaid readmissions

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Hospital partnerships with post-acute and long-term care facilities are crucial to reducing Medicaid readmissions, and providers now can refer to a new report and free toolkit to help forge these relationships, a government agency announced Wednesday.

The guide from the Agency for Healthcare Research and Quality is the only federal tool available that focuses on reducing readmissions of Medicaid beneficiaries, the organization stated.

Most readmission reduction efforts so far have focused on Medicare beneficiaries, largely because Medicare readmission rates have been tied to reimbursements. However, the rise of managed care and other payment models means hospitals increasingly are under pressure to reduce readmissions across the board, the report notes. And adult Medicaid patients admitted to the hospital for reasons other than childbirth are readmitted at rates that are “as high or higher” than Medicare beneficiaries, according to AHRQ.

Section Five of the six-section report focuses on collaborating with cross-setting partners. It includes an online toolkit for forming a cross-continuum team. The toolkit offers a template for a letter that hospitals could send to skilled nursing facilities and other providers to invite them to a community partnership meeting, with the goal being to improve transition practices.

The toolkit also includes an example of a cross-continuum team workplan, to help identify areas of focus, actions to be taken and timelines for completion. In the example, all skilled nursing facilities would complete the INTERACT Nursing Home Capabilities checklist.

“Cross‐continuum teams start with the providers with whom you commonly share high-risk patients,” the toolkit states. “Acknowledge that not all possible partners are at the table, and allow the group to expand naturally over time. Once you start hosting cross-continuum team meetings, other providers will want to be included.”

Click here to access the complete report and toolkit.
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