Analysis of a Social Work-Based Model of Transitional Care to Reduce Hospital Readmissions: Preliminary Data.

Efforts to reduce readmissions after hospital discharge are increasingly being made to better identify and address social and logistical needs in addition to attending to posthospital clinical challenges. A transitional care model based in the social work professional skill set may be well matched to assess and address social and logistical needs during the posthospital transitional care period. The effect of a social work-based transitional care intervention on all-cause 30-day readmission rates for Medicare fee-for-service (FFS) beneficiaries discharged from an urban medical center was analyzed.

Understanding Patient, Provider, and System Factors Related to Medicaid Readmissions.

Background: Efforts on reducing hospital readmissions, which are intended to improve quality and reduce costs, tend to focus on elderly Medicare beneficiaries without recognition of another high-risk population--adult nonmaternal Medicaid patients. This study was undertaken to understand the complexity of Medicaid readmission issues at the patient, provider, and system levels.

Methods: Multiple qualitative methods, including site visits to nine safety-net hospitals, patient/family/caregiver inter views, and semistructured interviews with health plans and state Medicaid agencies, were used in 2012 and 2013 to obtain information on patient, provider, and system issues related to Medicaid readmissions; strategies considered or currently used to address those issues; and any perceived financial, regulatory or, other policy factors inhibiting or facilitating readmission reduction efforts.

Coverage expansion and the criminal justice-involved population: implications for plans and service connectivity.

People who have served time in US prisons and jails have high rates of undiagnosed chronic and infectious diseases, behavioral health conditions, and trauma. Because a large portion of this population are young men-a demographic previously underrepresented in Medicaid rolls-who have been uninsured, Medicaid payers and the managed care plans they contract with have little experience serving this population. To meet the Affordable Care Act's policy objectives of cost-efficient and effective care through improved and expanded access, health plans need to understand the epidemiology and care-seeking patterns of this population.

Emergency department visits after hospital discharge: a missing part of the equation.

Study Objective: Current methods of measuring hospital readmissions capture only inpatient-to-inpatient hospitalization and ignore return visits to the emergency department (ED) that do not result in an admission. The relative importance of the return ED visit is currently not well established. We conduct this study to characterize the frequency of ED utilization within 30 days of inpatient hospital discharge.

An early look at a four-state initiative to reduce avoidable hospital readmissions.

Launched in 2009, the State Action on Avoidable Rehospitalizations initiative, known as STAAR, aims to reduce rates of avoidable rehospitalization in Massachusetts, Michigan, Ohio, and Washington by mobilizing state-level leadership to improve care transitions. With the program two years into its four-year cycle, 148 hospitals are working in partnership with more than 500 cross-continuum team partners. Although there are no publicly available data on whether the project is achieving its primary goal of reducing avoidable rehospitalizations, the effort has so far been successful in aligning numerous complementary initiatives within a state, developing statewide rehospitalization data reports, and mobilizing a sizable number of hospitals to work on reducing rehospitalizations.

Arrested on heroin: a national opportunity.

Objectives: Heroin addiction in the United States exacts significant social, economic, medical, and public health costs, estimated at almost $22 billion in 1996. The national drug control strategy of arrest and mandatory sentencing of drug offenders over the past two decades has resulted in ever greater numbers of drug users who encounter the criminal justice system each year. No estimate of heroin use among the U.

Attitudes and practices regarding the use of methadone in US state and federal prisons.

In the United States, vigorous enforcement of drug laws and stricter sentencing guidelines over the past 20 years have contributed to an expanded incarcerated population with a high rate of drug use. One in five state prisoners reports a history of injection drug use, and many are opiate dependent. For over 35 years, methadone maintenance therapy has been an effective treatment for opiate dependence; however, its use among opiate-dependent inmates in the United States is limited.

Opportunities to address the hepatitis C epidemic in the correctional setting.

An estimated 15%-40% of incarcerated persons in the United States are infected with hepatitis C virus (HCV). Approximately 1.4 million HCV-infected persons pass through the corrections system annually, accounting for one-third of the total number of HCV-infected persons in the United States.