Transitional care innovation for Medicaid-insured individuals: early findings.

ABSTRACT

BACKGROUND: Chronically ill adults insured by Medicaid experience health inequities following hospitalisation. LOCAL PROBLEM: Postacute 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. METHODS: An interdisciplinary team introduced a clinical pathway called 'THRIVE' to provide postacute wrap-around services for individuals insured by Medicaid. INTERVENTION Enrolment 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. RESULTS: Compared 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 %). CONCLUSION: THRIVE is a promising clinical pathway that increases access to ambulatory care after discharge and may reduce readmissions and ED visits.