CMS Issues Guide on Avoiding Readmissions in Diverse Populations

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By Michael D. Williamson

Jan. 26 — Hospitals are being asked to follow a set of recommendations aimed at preventing avoidable readmissions among racially and ethnically diverse Medicare beneficiaries that the CMS outlined in a Jan. 26 guide.

Many of the practices outlined in the Centers for Medicare & Medicaid Services guide are already being implemented by hospitals, Akin Demehin, senior associate director of policy at the American Hospital Association, an industry group, told Bloomberg BNA in a Jan. 26 e-mail.

The “Guide to Preventing Readmissions Among Racially and Ethnically Diverse Medicare Beneficiaries” also includes examples of initiatives and strategies that may be applied to reduce readmissions in diverse populations. “Racial and ethnic minority populations are more likely than their white counterparts to be readmitted within 30 days of discharge for certain chronic conditions, such as heart failure, heart attack, and pneumonia, among others,” the CMS said in a press release.

Social, cultural and linguistic barriers also contribute to higher readmission rates among diverse beneficiaries, according to the guide, which was released by the CMS Office of Minority Health (OMH).

Research has demonstrated that unplanned readmissions cost Medicare $17.4 billion in 2004, the guide said, adding that 20 percent of Medicare fee-for-service patients were readmitted within 30 days of discharge. The report said as a result of these statistics, the CMS, through congressional direction and Obama administration initiatives, implemented the Hospital Readmissions Reduction Program (HRRP) in 2012, which penalizes hospitals with relatively higher rates of Medicare readmissions.

Data Collection Key

The first step toward reducing readmissions among racially and ethnically diverse populations is to collect data that identifies who is commonly being readmitted, for what condition, from what location, due to what factors, and at what cost, according to the guide. “Developing a better understanding of these particulars is essential to having a strong grasp on what underlies the readmission rate,” the CMS said. In particular, the guide called on providers and researchers to collect demographic information about the race, ethnicity, language, education status, social determinants (factors such as social support, access to healthy foods and safe, affordable places to exercise, availability of transportation, etc.), and disability status of readmitted patients.

The AHA's Demehin told Bloomberg BNA that many hospitals have redoubled their efforts to use data to identify opportunities for improvement. “Indeed, nearly 1,000 hospitals and 35 state and metropolitan hospital associations have pledged to examine their performance on quality measures by race, ethnicity, and language, and implement plans to address any disparities in care,” Demehin said.

Once data effectively identify the “targets” or those patients, populations and characteristics that are linked to readmissions, providers can begin a process that focuses on addressing the barriers and developing systems to prevent them, the report said. “Familiarity with the target should lead to a series of preemptive efforts that span the duration of pre-admission to post-discharge. These efforts are especially important for vulnerable, minority populations where complexity may require more time for providers to effectively communicate and address patients’ needs,” the guide said.

Moreover, the CMS recommended that hospitals and other providers develop a team approach to avoiding readmissions among diverse populations. All evidence points to the risks for readmissions being myriad and involving many factors and these risks can't be addressed solely by doctors, nurses or social workers, the guide said. Success will be predicated on a multidisciplinary team—which may include pharmacists, nutritionists, mental health providers, substance abuse services and other nontraditional health professionals—that is able to effectively communicate the steps that patients can take to avoid readmissions.

Recommended Interventions

The guide also suggested hospitals develop interventions to prevent readmissions, especially in vulnerable, minority populations, through:

• creating systems responsive to the needs of diverse populations;
• ensuring patients have the social supports that they need to manage their condition; and
• addressing the social determinants that put them at continued and repetitive risk for readmission.


The purpose of the guide is to better position the CMS to support “Quality Improvement Networks and Quality Improvement Organizations (QIN-QIOs); Hospital Engagement Networks (HENs); federal, state, local, and tribal organizations; providers; researchers; policymakers; beneficiaries and their families; and other stakeholders in activities to achieve health equity,” the report said. It also said priorities, activities and recommendations described in the document were identified during a year-long process that included examining the evidence base, identifying opportunities and gathering stakeholder input, according to the agency.

The OMH, in collaboration with National Opinion Research Center at the University of Chicago, produced the report as part of its broad range of work to achieve health equity.

To contact the reporter on this story: Michael D. Williamson in Washington at

To contact the editor responsible for this story: Janey Cohen at

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