Medicare issues guide to preventing readmissions of minority patients

The guide offers strategies to handle challenges such as linking patients to postdischarge follow-up, dealing with limited English proficiency or health literacy, and incorporating cultural beliefs and customs into care.


A guide offering recommendations for clinicians and hospital leaders on how to reduce readmissions among racially and ethnically diverse Medicare patients was released by CMS last week.

The guide offers strategies to handle challenges such as linking patients to postdischarge follow-up, dealing with limited English proficiency or health literacy, incorporating cultural beliefs and customs into care, overcoming social determinants of health, identifying and treating anxiety and depression, and ensuring that all comorbidities are adequately treated.

The guide also includes 7 high-level recommendations for hospital leaders working on readmission prevention:

  • Create a strong data collection “radar”
  • Identify the root causes of readmissions
  • Start from the start of admission rather than later during the hospitalization
  • Deploy a multidisciplinary team
  • Consider systems and social determinants
  • Focus on culturally competent, communication-sensitive, high-risk scenarios
  • Foster community partnerships to promote continuity of care

The guide also includes case studies of interventions that have succeeded in preventing avoidable readmissions, highlighting components that are particularly relevant to minority populations. It was developed with support from the CMS Office of Minority Health by the Disparities Solutions Center at Massachusetts General Hospital, in partnership with NORC at the University of Chicago, and is available for download.