How do hospitals that serve low socioeconomic status patients achieve low readmission rates? A qualitative study of safety-net hospitals

BACKGROUND: Hospital readmissions are an important quality of care indicator and are tied to hospitals' financial reimbursements. Safety-net hospitals, which serve a high proportion of patients of low socioeconomic status (SES), face unique challenges to reduce or maintain low readmission rates. 

OBJECTIVE: We sought to understand strategies high-performing safety-net hospitals used to achieve low 30-day risk-standardised readmission rates (RSRRs) using qualitative methodology. 

METHODS: Safety-net hospital status was defined by public ownership or a Medicaid population that is greater than 1 SD higher than the state proportion of Medicaid patients and the hospital payer source is composed of at least 15% Medicaid patients. Safety-net hospitals were selected based on their ranking among the lowest 20% of heart failure RSRRs, the best-performing quintile. We purposefully sampled hospitals to ensure variation in characteristics and conducted on-site interviews with key hospital staff. A multidisciplinary team analysed the data using thematic analysis. 

RESULTS: We performed site visits at 9 safety-net hospitals (RSRR range: 18.1%-21.6%) in 9 states and conducted in-depth interviews with 108 hospital staff. Several thematic attributes and organisational strategies were evident in high-performing safety-net hospitals: (1) strong hospital support for quality improvement at all levels; (2) tailoring resources to meet patient needs; (3) facilitating collaboration and communication among and between providers and patients; (4) creating strong relationships with postacute care facilities and communities and (5) proactive approach to healthcare policy changes and other external factors. 

CONCLUSIONS: The provision of high-quality and equitable care in hospitals serving a high proportion of low-SES populations is influenced by several modifiable factors. These findings may serve to inform lower-performing safety-net hospitals on how to optimise patient care and improve readmission outcomes.