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AHRQ's Hospital Guide to Reducing Medicaid Readmissions was used by Blue Shield of California Foundation to apply evidence-based strategies that significantly cut hospital readmissions among adult Medicaid patients. The Foundation used the ´óÏóÊÓƵguide with community health centers and clinics to help ensure the best possible care and services for Californians most in need.

The work, part of the Foundation's Advancing Care Coordination and Integration (ACCI) portfolio, was led by nine community health center and clinic teams that pursued goals of the National Quality Strategy's three broad aims for better health care, improved population health, and reduced costs.  

The teams' efforts to support care transitions and improve care coordination for more than 14,000 patients over 15 months led to significant successes.

• The Community Health Center Network team in Alameda County implemented a care management program focusing on 70 frequent emergency care and hospital users with multiple medical conditions. Readmissions decreased to 6 percent from 29 percent, with 70 percent of patients reporting top ratings for program satisfaction.
• The Open Door Community Health Center team in Humboldt County implemented a post-acute care transitions program for 3,000 clinic patients receiving hospital care, plus a care management program for highest-need patients. The hospital readmission rate was reduced in four clinics with estimated savings of nearly $2.2 million over 18 months. One clinic's readmission rate fell to approximately 9 percent from more than 13 percent.
• The Petaluma Health Center team in Sonoma County implemented care management for 300 patients with a history of frequent inpatient and emergency care. The hospital readmission rate fell to less than 10 percent from about 13 percent.

"The challenges faced by safety net providers are unique, so we are constantly looking for tools to support their health care transformation work," explained Rachel Wick, M.P.H., senior program officer for the Foundation's Health Care and Coverage program. "AHRQ's Hospital Guide to Reducing Readmissions resonated with our teams, because the tools were relevant to their patients' needs and easily applicable to practice changes that support smooth transitions and care coordination."

Among the ´óÏóÊÓƵtools ACCI implemented included:

• Portfolio Design Tool—a prompt for readmission-reduction teams to expand progress in at least three broad domains: improving standard care for Medicaid patients, collaborating with partners, and providing enhanced services for high-risk patients.
• Readmission Review Tool—a review guide that prompts clinical or quality staff to solicit patient, caregiver, and provider perspectives about readmission causes.
• Readmission Risk Tool—an educational and awareness-building tool that helps frontline staff, cross-continuum teams, and quality improvement leaders quickly review the many factors leading to readmission.
• Discharge Information Checklist—a checklist of information that must be provided to patients and their receiving providers when patients leave the hospital.
• Community Resource Guide Tool—a prompt for hospital readmission-reduction teams to identify specific community agency contacts for efficient referrals to resources patients may need.