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Care coordination, SDOH focus helped NY reduce Medicaid readmissions by 18%

As we all know, Medicaid systems are under intense pressure to redesign care and improve outcomes. Kudos to New York on an innovative approach that is showing great results. Through their Delivery System Reform Incentive Payment (DSRIP) efforts, the state Department of Health recently reported an 18-percent decrease in hospital readmissions for high-risk Medicaid patients over a three-year period.

These improvements come by way of the work of New York’s Medicaid Accelerated eXchange (“MAX”) Series, whose 22 Action Teams localized groups of multidisciplinary hospital and community health providers developed innovative strategies to more effectively treat the state’s most vulnerable patients.

Sample strategies they've employed include:

  • Improved identification of at-risk patients through ED-based encounter-based alerts and flags (to improve care management after the ED visit)
  • Designated personnel to serve as care managers through transitions of care, especially transitions to home and community-based services
  • Standardized clinical guidelines and care plans that address known likely issues that arise during transitions of care
  • Perhaps most importantly, an SDOH focus with an emphasis on patient and family engagement, and asking the patient what other non-medical needs they may have at any point in time

Executives across the state cite the MAX Series’ focus on the health of the whole person as the basis for its success. By taking a more detailed examination of patient lives, Action Teams have uncovered these patients’ previously unseen struggles the social determinants that ultimately have a powerful impact on their overall health and well-being.

New York Medicaid Director Donna Frescatore commented, “Many times, the answer may be that the patient needs help with housing, making or getting to doctor's appointments, or help taking their medications. By focusing on the patient and thinking in a different way, the MAX Series has not only reduced hospital admissions and readmissions, it's made a difference in the lives of these patients.”

How is your organization innovating to reduce Medicare costs/quality of care?  Please share your ideas!


Amy Vreeland

Learn more

NY Department of Health Announces Results of Medicaid Redesign Efforts, Improving Patient Care

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