Document Type


Publication Date

Fall 2018


The Centers for Medicare and Medicaid (CMS), the Joint Commission (TJC), Institute for Healthcare Improvement (IHI), and the Agency for Healthcare Research and Quality (AHRQ) have all highlighted readmissions as an issue in healthcare that needs to be addressed. Many of these organizations have piloted programs which aim to decrease readmissions.

The MAP (Medication Focus, Access Assistance, and Provider Collaboration) program seeks to decrease the readmission rate of high-risk patients. Readmissions are costly and often lead to negative patient outcomes. To decrease cost to the hospital and avoid penalties from the Centers for Medicare and Medicaid (CMS), the MAP program was created to support patients after discharge. Patients who are identified as high risk for readmission are referred to the program and contacted by a home health agency which has a partnership with the department. They receive an in-person home health visit and telephone calls with a medical social worker (MSW). Patients who were high-risk but did not receive services between April and June 2018 had a readmission rate of 25.58%, while patients who received the MAP services had a readmission rate of only 8.96%. This program has decreased the overall readmission rate of patients who otherwise had a high-risk of returning to the hospital within 30 days.