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

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.