Integrated Care Needed for Minority Population Health to Address Hospital Readmissions
System transformations focused on preventing avoidable admissions must address health disparities that continue to exist among minority populations. A paradigm shift from an acute care model to an integrated care model for complex chronic diseases is not sufficient when the systematic barriers to care continue to exist for minority populations and mental health and substance treatment remain elusive. With the drive from the Centers for Medicaid and Medicare Services (CMS) to reducepreventable avoidable admissions and legislation that can be enacted in 2016 to reduce Medicare payments by three percent under the Medicare Hospital Readmissions Reduction Program (HRRP),the possibility of not addressing minority population health needs comes at a considerable financial risk to hospitals, particularly safety-net hospitals. Of the estimated two million patients who return to care post discharge from hospitals costing Medicare $26 billion dollars, an estimated $17 billion is recoverable due to potentially avoidable admissions. For certain States in the advanced stage of an Innovation Model award, the financial risk can be much higher than a three percent reduction in payment.
Necessary steps for addressing health disparities at the hospital level includes:
- Developing a Transitions/Readmission Care Team. This team must be equipped to redesign administrative, business, clinical and financial practices and policies that reflect a proven knowledge of minority health issues and solutions to the barriers in care that minorities face when entering the health care system.
- Committing to a through gap analysis for barriers to care across minority population needs. This includes looking at: care transitions needs prior to discharges; linkages to both usual and unfamiliar community sources of care; language access barriers; health literacy at all levels of care and decision-making by both staff and patients; the provision of culturally competent patient education material; social and community resources (both formal and informal); complex care integration and access; and culturally relevant program supports for behavioral health and medical co-morbidities to address medication adherence and treatment follow-up.
- Developing a planned approach to include training, data infrastructure, and policy to practice changes with input from community resources to address transitions and adherence to care.
- Identifying specific steps for practice changes and measurable goals capturing the cultural values, norms and beliefs of the assessment, activation, and treatment adherence and retention processes.
Analytics in the data system must flag the following conditions according to CMS: heart failure, heart attack, pneumonia, chronic obstructive pulmonary disease (including emphysema and bronchitis), and elective hip and knee replacements. Clinical outcomes for these conditions in specific minority populations tend to show minimal to no improvements. This indicates continued high cost care, poor health care resources, and inadequate treatment engagement that lack the potential assets of culturally relevant patient engagement strategies. Co-morbid mental health and substance abuse disorders and complex care behavioral health and medical co-morbidities must be integrated into the analytics, due to their high initial avoidable emergency department admission rates that cycle into high avoidable re-admissions.
Continuing to underserve the underserved is not a viable option. While health disparities and inequalities continue to exist, the impact now clearly includes high risk to, and potential loss of under-performing provider systems, particularly those safety-net systems that serve poor disenfranchised populations. Improvements in minority health care can only be reached by improvements in integrated health care delivery systems that recognize and incorporate the cultural values, norms and beliefs of the minority populations they serve as an integral part of their treatment.
SAE's Approach to Evaluation: https://www.youtube.com/watch?v=MzNyWyVmkKE