Image of male nurse pushing senior woman in a wheelchair in nursing facility

Lack of communication about care transitions and limited health literacy are among the primary reasons minority patients are readmitted to the hospital, according to a new federal guide.

The Centers for Medicare & Medicare Services’ guide, released Tuesday, aims to prevent readmissions among “racially and ethnically diverse” Medicare beneficiaries. These populations are readmitted more often than white patients due to cultural, social and health barriers including limited English proficiency, a lack of socioeconomic resources and multiple co-morbidities.

Discharge plans are often a factor in whether a minority patient will be readmitted to the hospital. Providers should give early discharge planning and follow-up instructions for patients at high readmission risk, and provide support to patients who may need assistance with follow-up care due to issues like language barriers or lack of transportation.

The guide also noted that families should be engaged during care transitions, and patients’ cultural beliefs should be used to promote self-care and family support. Providers may also link patients to programs or post-acute facilities that align with their cultural beliefs.

The number of newly insured Americans will “mirror the diversity” of the country within the healthcare spectrum, according to the guide.

“In the current environment, healthcare systems are searching for quick ‘wins,’ or areas of focus that are promising and provide high return-on-investment — ‘high-value’ targets,” the guide reads. “If we are progressive, thoughtful, and truly gearing up for success, a new healthcare system that is high-value, equitable, culturally competent and delivers quality care to all is well within reach.”

The “Guide to Preventing Readmissions among Racially and Ethnically Diverse Medicare Beneficiaries” is part of the CMS Equity Plan for Improving Quality in Medicare.