The Centers for Medicare & Medicaid Services (CMS) implemented the Hospital Readmissions Reduction Program (HRRP) in 2012. Since then, unplanned 30-day readmissions for targeted conditions among Medicare enrollees have notably decreased. Research indicates that disparities in these readmission rates, particularly between non-Hispanic White and Black patients, have narrowed post-implementation.
However, baseline readmission levels remain higher for Black patients compared to White patients. Various sociodemographic factors, including rural residence, disability, and LGBTQI+ identity, continue to contribute to higher readmission rates among underserved populations. Addressing these disparities is central to CMS’s 2022 Strategic Plan and Framework for Health Equity 2022-2032, which emphasize identifying and mitigating social determinants of health (SDOH). To aid healthcare organizations and providers in reducing avoidable readmissions and disparities, the CMS Office of Minority Health has developed a Guide focused on early SDOH intervention.
This initiative is part of a broader CMS endeavor to tackle social determinants of health (SDOH). It aligns with CMS goals to integrate screening for and access to health-related social needs throughout its programs and activities. This includes increased adoption of relevant quality measures, enhanced collaboration with community-based organizations, and standardized collection of social needs data.
The social, economic, and environmental factors influencing individuals from birth through aging significantly impact their healthcare journeys and overall health outcomes. The U.S. Department of Health and Human Services’ Healthy People 2030 Framework prioritizes addressing these social determinants of health (SDOH) due to their profound role in creating health disparities and inequities. Research suggests that SDOH accounts for 50% of all health outcomes, whereas clinical care influences only 20% of county-level variations in health outcomes.
Several factors contribute to the disparities observed in hospital readmission rates, with insurance status emerging as a critical factor. Lack of insurance can heighten the risk of readmission due to reduced access to outpatient care. Despite Medicare coverage among insured individuals, other social determinants of health (SDOH) significantly impact readmission rates. Factors such as lower education and income levels, limited transportation access, unstable housing, inadequate food security, and lack of social support have all been linked to higher rates of readmission. These SDOH are influenced by political, economic, and cultural factors that shape the distribution of power and resources. Extensive research indicates that the unequal allocation of these resources has contributed to disproportionately poor outcomes for racial and ethnic minority groups.
Additional Tools:
- GPQIN: Readmissions Interview Tool
- GPQIN: Reducing Avoidable Emergency Department Visits & Hospitalization Toolkit
- GPQIN Connecting the Dots – Antibiotic Stewardship, Immunization, Sepsis
- GPQIN When to Call for Help Tool
- GPQIN When to Call for Help Tool Booklet Version (Print Setting: Print On Both Sides: Flip pages on short edge)
- GPQIN Checklist For When To Call For Help
Listen To Our Focus 4 Health Series!
July 2023 | Multi-Visit Patient (MVPs) – Reducing Preventable ED Visits 
- Week One: Multi-Visit Patient (MVP) Method & Implicit Bias Connection I Recording
- Week Two: Utilizing Community Health Workers (CHW) to reduce MVPs | Recording
- Week Three: Reducing Avoidable ED Visits by Working Together in the Community | Recording
- Week Four: Coordinating Care, Communication, and Trust is a Must to Help MVPs | Recording
October 2023 | A Culture of Safety
- Week One: Culture of Safety in Healthcare | Recording
- Week Two: High Reliability Organizations | Recording
- Week Three: TeamSTEPPs | Recording
- Week Four: Just Culture | Recording