Hospital Guide to Reducing Medicaid Readmissions

Reducing readmissions is a national priority for payers, providers, and policymakers seeking to improve health care and lower costs. Readmissions are a significant issue among patients with Medicaid. The Agency for Healthcare Research and Quality (AHRQ) commissioned this guide to identify ways evidence-based strategies to reduce readmissions can be adapted or expanded to better address the transitional care needs of the adult Medicaid population.

Prepared by:

Collaborative Healthcare Strategies, Inc.
Amy Boutwell, M.D., M.P.P.

John Snow, Inc.
James Maxwell, Ph.D.
Angel Bourgoin, Ph.D.
Sarah Genetti, B.A.


About the Principal Investigators
Why Focus on Medicaid Readmissions?
How To Use This Guide
Overview of Guide Content
Roadmap of Tools
Section 1: Know Your Data
Section 2: Inventory Readmission Reduction Efforts
Section 3: Develop a Portfolio of Strategies
Section 4: Improve Hospital-Based Transitional Care Processes for Medicaid Patients
Section 5: Collaborate With Cross-Setting Partners
Section 6: Provide Enhanced Services for High-Risk Patients

Introduction to the Tools
Tool 1: Data Analysis Tool (Word® File, 51 KB; PDF File, 178 KB)
Tool 2: Readmission Review Tool (Word File, 59 KB; PDF File, 293 KB)
Tool 3: Data Analysis Synthesis Tool (Word File, 68 KB; PDF File, 308 KB)
Tool 4: Hospital Inventory Tool (Word File, 50 KB; PDF File, 233 KB)
Tool 5: Cross-Continuum Team Inventory Tool (Word File, 72 KB; PDF File, 350 KB)
Tool 6: Conditions of Participation Checklist Tool (Word File, 49 KB; PDF File, 338 KB)
Tool 7: Portfolio Design Tool (Word File, 107 KB; PDF File, 419 KB)
Tool 8: Readmission Reduction Impact and Financial Analysis Tool (Excel® File, 46 KB; Word File, 46 KB; PDF File, 330 KB)
Tool 9: Readmission Risk Tool (Word File, 45 KB; PDF File, 247 KB)
Tool 10: Whole-Person Assessment Tool (Word File, 57 KB; PDF File, 292 KB)
Tool 11: Discharge Information Checklist (Word File, 45 KB; PDF File, 281 KB)
Tool 12: Cross-Continuum Team How To Tool (Word File, 64 KB; PDF File, 352 KB)
Tool 13: Community Resource Guide Tool (Word File, 55  KB; PDF File, 248 KB)

Prepared for the Agency for Healthcare Research and Quality under Contract No. HHSA290201000034I.

This document is in the public domain and may be used and reprinted without permission except those copyrighted materials noted for which further reproduction is prohibited without specific permission of copyright holders.

No investigators have any affiliations or financial involvement (e.g., employment, consultancies, honoraria, stock options, expert testimony, grants or patents received or pending, or royalties) that conflict with material presented in this report.

Page last reviewed August 2014
Internet Citation: Hospital Guide to Reducing Medicaid Readmissions. Content last reviewed August 2014. Agency for Healthcare Research and Quality, Rockville, MD.