Transitional care innovation for Medicaid-insured individuals: early findings

Abstract

BackgroundChronically ill adults insured by Medicaid experience health inequities following hospitalisation.Local problemPostacute outcomes, including rates of 30-day readmissions and postacute emergency department (ED), were higher among Medicaid-insured individuals compared with commercially insured individuals and social needs were inconsistently addressed.MethodsAn interdisciplinary team introduced a clinical pathway called ‘THRIVE’ to provide postacute wrap-around services for individuals insured by Medicaid.InterventionEnrolment into the THRIVE clinical pathway occurred during hospitalisation and multidisciplinary services were deployed into homes within 48 hours of discharge to address clinical and social needs.ResultsCompared with those not enrolled in THRIVE (n=437), individuals who participated in the THRIVE clinical pathway (n=42) experienced fewer readmissions (14.3% vs 28.4%) and ED visits (14.3% vs 28.8 %).ConclusionTHRIVE is a promising clinical pathway that increases access to ambulatory care after discharge and may reduce readmissions and ED visits.

Perspectives on supporting Veterans’ social needs during hospital to home health transitions: findings from the Transitions Nurse Program

“…Process innovations in community settings show promising results to improve care coordination and communication issues between healthcare systems and HHC. THRIVE, a clinical pathway developed to support individuals insured by Medicaid in the transition from community hospital to HHC, includes community health workers who address patients’ social needs and has shown preliminary reductions in 30-day readmission and emergency department use compared to baseline [ 8 ]. Industry partnerships continue to grow with SDOH information exchanges working with health plans, state governments, and healthcare systems, such as ChristianaCare’s partnership with Unite Us, to provide geographically tailored social needs resources for patients [ 25 – 27 ].…”

“…The care transition from hospital to home is one of the most vulnerable times and patients receiving HHC have higher acuity that put them at greater risk for adverse outcomes during this period [ 7 ]. As social needs drive physical health outcomes, Veterans with social needs may have compounded risk during an already vulnerable time [ 3 , 8 ]. Additionally, acute care is focused on stabilizing a patient to return to home and may not be the appropriate setting to address social needs longitudinally.…”

Equity Centered Post Discharge Support for Medicaid Insured: A Type 1 Hybrid Effectiveness Implementation Stepped-Wedge Cluster Randomized Trial Study Protocol For The ‘THRIVE’ Clinical Pathway

“…Published results from a non-randomized pilot of the rst year of the THRIVE pathway revealed that participants experienced increased connections to post-acute care services, including social support, and 50% decrease in rates of 30-day readmissions and ED utilization compared to patients receiving standard care. 42 With these early ndings, we are now poised to evaluate a scalable and sustainable post discharge management process in a new setting, and with a more rigorous evaluation and attention to organization factors in uencing success.…”

Equity-Centered Postdischarge Support for Medicaid-Insured People: Protocol for a Type 1 Hybrid Effectiveness-Implementation Stepped Wedge Cluster Randomized Controlled Trial

“…Published results from a nonrandomized pilot of the first year of the THRIVE pathway revealed that participants experienced increased connections to postacute care services, including social support, and a 50% decrease in rates of 30-day readmissions and ED use compared to patients receiving standard care [ 42 ]. With these early findings, we are now poised to evaluate a scalable and sustainable postdischarge management process in a new setting and with a more rigorous evaluation and attention to organizational factors influencing success.…”