Hospital Guide to Reducing Medicaid Readmissions Toolbox

Agency for Healthcare Research and Quality (AHRQ)

Offers in depth information about the unique factors driving Medicaid readmissions and a step-by-step process for designing a locally relevant portfolio of strategies to reduce Medicaid readmissions. Toolkit includes patient and family interview process.

Mapping Medicare Disparities

Centers for Medicare and Medicaid Services (CMS), Office of Minority Health (OMH)

Chronic diseases pose a significant problem in the United States resulting in substantial morbidity, mortality, disability, and cost. The CMS Office of Minority Health has designed an interactive map, the Mapping Medicare Disparities Tool, to identify areas of disparities between subgroups of Medicare beneficiaries (e.g., racial and ethnic groups) in health outcomes, utilization, and spending. It is an excellent starting point to understand and investigate geographic and racial and ethnic differences in health outcomes. This information may be used to inform policy decisions and to target populations and geographies for potential interventions.

Safer Together: A National Action Plan to Advance Patient Safety

Institute for Healthcare Improvement (IHI)

Safer Together: A National Action Plan to Advance Patient Safety provides clear direction that health care leaders, delivery organizations, and associations can use to make significant advances toward safer care and reduced harm across the continuum of care. This resource also includes a Self-Assessment Tool & Implementation Resource Guide. Resource also includes case examples on engaging patients and families in safety.

Training and the Culture of Learning: Health Equity Resource Series

American Hospital Association (AHA) Institute for Diversity and Health Equity (IFDHE)

To support hospitals and health systems starting from different points on their journey to achieve health equity, the AHA’s Institute for Diversity and Health Equity (IFDHE) is releasing a series of toolkits to share evidence-based practices to inform organizational next steps for the following topics:

  • Data collection, validation, stratification and application of patient information to address disparate outcomes
  • Cultural humility and implicit bias training and education
  • Diversity and inclusion in leadership and governance roles
  • Sustainable community partnerships focused on improving equity

Each toolkit is designed to be informative, whether organizations have already deployed health equity tactics and strategies or if they are at the early stages of implementation. Each helps lay the groundwork for an in-development equity roadmap to support hospitals’ and health systems’ efforts toward achieving high-quality, equitable care for all. This toolkit focuses on training and education strategies and approaches to encourage cultural humility and overcome implicit bias.

Person and Family Engagement and Health Equity – Summary

This material was prepared by American Institutes for Research (AIR). It is redistributed by IPRO HQIC, a Hospital Quality Improvement Contractor, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS).

This is a summary table that describes the six strategies for engaging with patients and families in equitable and meaningful ways. Although the order of the strategies in the table is based on hospitals’ experiences, hospitals do not need to implement all six strategies at once, or in this order.

PfP Strategic Vision Roadmap for Person and Family Engagement (PFE)

This material was prepared by American Institutes for Research (AIR). It is redistributed by IPRO HQIC, a Hospital Quality Improvement Contractor, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS).

The purpose of the revised Roadmap is to provide practical guidance to help the Hospital Improvement Innovation Networks (HIINs), hospitals, and other PfP partners achieve a shared vision of PFE and meet the five PFE metrics.

The Roadmap contains information about:
• definition and core principles of PFE;
• role of PFE in patient safety;
• the intersection of PFE and health equity;
• definition, intent, and benefits of each PFE metric, as well as tips and resources to help
meet each metric and hospital success stories; and
• six PFE strategies to meet the five PFE metrics.

Minority Health SVI

US Department of Health and Human Services offices of Minority Health

The Centers for Disease Control and Prevention (CDC) and U.S. Department of Health and Human Services (HHS) Office of Minority Health developed the Minority Health Social Vulnerability Index (SVI) to enhance existing resources to support the identification of racial and ethnic minority communities at greatest risk for disproportionate impact and adverse outcomes due to the COVID-19 pandemic. Given evidence on common factors contributing to social vulnerability, the MH SVI could potentially be applied to other public health emergencies.

Social Determinants of Health for Rural People

The Rural Health Information Hub

This resources discusses the contributing social factors that impact the health of rural residents. It provides a guide that focuses on the barriers and challenges that rural residents experience and discusses the impact of and documenting rural differences related to: Income-level, educational attainment, race/ethnicity, and health literacy.

Person and Family Engagement and Health Equity

Developed by American Institute of Research (AIR) in partnership with IPRO HQIC

Person and family engagement (PFE) is recognized by the Centers
for Medicare & Medicaid Services (CMS) as a promising way to
address health and health care disparities and achieve equity in
quality and safety
. Applying PFE equitably means including
patients and families from all backgrounds as equal and active
partners in their health care. Doing so can help ensure that all
patients reap the benefits of engagement in their healthcare.

Health Disparities Road Map

Developed by American Institute of Research (AIR) in partnership with IPRO HQIC

This resource discussed how Person and Family Engagement can help hospitals achieve health Equity in Health Care Quality and Safety.

The American Institutes for Research (AIR)—a partner in the IPRO HQIC program—identified six overarching strategies to guide hospitals in meaningfully engaging patients and families in health care. This document describes how to apply these strategies in ways that can help hospitals achieve equity in care quality and safety and address barriers to uniform engagement.