Care Transformation Center Blog

4 tactics for reducing readmissions and health disparities

by Catherine Castillo and Rebecca Tyrrell

CMS recently released a guide to reducing readmissions in racially and ethnically diverse populations. The guide contains many tactics commonly seen in readmissions reduction programs across the country, such as early discharge planning, patient education, depression screening, care transitions support, and timely PCP follow up.

While these strategies work and target risk factors that can disproportionately affect minorities—lack of care continuity, health literacy, mental health comorbidities, and more—these tactics alone are not enough. Here are four ways providers can adapt their approach to meet the unique needs of diverse populations.

Capture data to size the problem

Before addressing racial and ethnic disparities, you will need a better understanding of which patient groups in your population are commonly readmitted and their related risk factors. While many organizations already gather social determinants data, it is recommended that all providers also routinely collect race, ethnicity, preferred language, and health literacy data to better pinpoint the needs of patients.

Meaningfully increase language access

Limited English proficiency is associated with lower utilization of preventive services, medication adherence, and comprehension of discharge diagnosis and instructions. At the most basic level, providers should ensure access to professional medical interpreters at all points of care. The most skilled interpreters will account for low health literacy when interpreting. To further enhance language access, providers can go beyond the interpreter and provide patients and caregivers with written materials, such as discharge instructions, in their preferred language.

Leverage cultural values

The level of trust that patients have in providers and how they process medical advice is deeply influenced by their cultural beliefs and customs. At first blush, providers may see cultural differences as a barrier. It takes time to work with patient groups and community organizations to gain insight into cultural beliefs that impact the patient experience. However, viewing cultural differences as an asset and tapping into values of social support and personal wellness can be an excellent patient and family engagement lever, and a key component of building up your patient education program.

Engage community partners

Partnerships with trusted community organizations that address non-medical risk factors like financial barriers, behavioral issues, and health literacy in a culturally sensitive way help to connect patients to social support and educational programs. Organizations such as as faith-based organizations and cultural affinity groups can also help identify patients who might otherwise not access care, extending services beyond the hospital.

Email us for more information on the research we're doing on care transitions and community partnerships.

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