Reducing hospitalizations among MI Choice Medicaid Long Term Services and Supports (LTSS) participants
The Area Agency on Aging 1-B (AAA 1-B), located in southeast Michigan, has been conducting phone assessments and follow-up clinical interventions in order to reduce avoidable hospitalizations and readmissions for MI Choice Medicaid long-term services and supports participants. Participants are queried by phone about their immediate health status to predict the risk of hospitalization. When an elevated risk is identified, a clinical response--medical, social, or behavioral health services--is provided by a MI Choice support coordinator.
CHRT is supporting this work by analyzing monthly data to identify trends and assess the program’s progress and results. CHRT is employing its expertise in long-term services and supports practices and predictive modeling analysis, supplemented by a focused literature review, to help AAA 1-B identify effective measures, processes, and best practices to enhance program performance.