It's established fact that minorities and other vulnerable populations face a higher risk of hospital readmissions for conditions such as chronic heart failure or procedures such as total knee or hip arthroplasty. But that could change if hospitals and other health care providers started to comprehensively address the matrix of cultural, economic, and comorbidity issues faced by racially and ethnically diverse patients, according to a new publication from the US Centers for Medicare and Medicaid Services (CMS).

"While not all readmissions are entirely preventable, it is widely understood that a portion of unplanned readmissions could be avoided by addressing a series of barriers patients face prior to, during, and after admission and discharge," write authors of a recently release CMS guideline. The publication, titled "Guide to Preventing Readmissions Among Racially and Ethnically Diverse Medicare Beneficiaries," lays out key issues related to the higher readmission rates, and accompanies those issues with a set of ambitious strategies for reducing those rates.

The issues that contribute to higher readmission rates among racially and ethnically diverse patients, as identified by CMS, include lower rates of follow-up after discharge, fewer linkages to primary care providers, limited English proficiency in certain cases, degree of health literacy, cultural beliefs or customs that may influence health behaviors, socioeconomic barriers to resources, higher rates of anxiety and depression, and the effect of comorbidities.

The strategies suggested by CMS for addressing these disparities are wide-ranging, and depend in large part on increased levels of interdisciplinary collaboration, greater attention to patient education, and stronger connections with communities and resources outside the health care facility.

According to the guide, any effort to close the readmission gap must include strong patient data collection efforts to better understand the particular barriers each individual faces; readmission reduction strategies that begin even before admission; and the creation of true multidisciplinary, culturally competent teams to help coordinate care and educate the patient. Additionally, the CMS guide encourages the creation of better partnerships throughout the community "to ensure that the next care provider is aware of the patient's status and care information, and to direct at-risk patients to needed care following hospitalizations."

"CMS has an important opportunity and a critical role in preventing hospital readmissions while promoting health equity among diverse Medicare beneficiaries," said Cara James, director of CMS’s Office of Minority Health in a CMS news release. "This guide encourages action-oriented steps and solutions in achieving health equity, addresses reducing readmissions and focuses on our initiative of achieving better care, smarter spending, and healthier people throughout our health care system."

The guide also includes 3 case studies that CMS believes demonstrate efforts to reduce the readmission gap: a "re-engineered" discharge process; a system that incorporates telehealth into home health; and a "health connections" program that identified area "hot spots" of "super utilizers" and then delivered education and other programs to that population.

APTA highlights cultural competence as a crucial part of evidence-based practice on its Cultural Competence in Physical Therapy webpage, and offers additional online resources on the ways racial and ethnic disparities affect health care.racial and ethnic disparities affect health care.

Learn about how physical therapy can affect readmissions: check out "The Value of Physical Therapy in Reducing Avoidable Hospital Readmissions," offered through the APTA Learning Center, and “There's No Place Like Home: Reducing Hospital Readmission Rates,” a feature article in the November 2015 PT in Motion magazine.