Preventing Readmissions Among Ethnically Diverse Patients


A growing body of evidence indicates that racial and ethnic minority populations are at increased risk for hospital readmissions. Studies have shown that African Americans and Latinos are more likely to be readmitted to the hospital than whites. Additionally, minority patients are more likely to be readmitted for potentially preventable conditions, such as heart failure and pneumonia (Basu et al., 2018). Essentially, being from a low-income background increases the possibility of readmission.

As a matter of fact, there are several potential explanations for these disparities. One is that minority patients are more likely to have chronic conditions that increase their risk for readmission. Another is that they are more likely to live in poverty and lack access to adequate healthcare. Additionally, minority patients may be less likely to receive high-quality care due to language barriers or cultural differences (Rivera-Hernandez et al., 2019). Having support groups in hospitals, such as translators, ensures patients receive quality healthcare.

There is a growing recognition of the need to address disparities in hospital readmissions. In particular, efforts are undertaken in order to develop targeted interventions to reduce readmissions among racial and ethnic minority populations. These efforts are essential to ensuring that all patients have access to high-quality care and reducing the overall readmission burden on the healthcare system. The paper discusses how patients and medical practitioners can leverage health care technology, care coordination, and community resources to prevent readmission. The paper further discusses how medical practitioners should interact with patients to know the challenges they undergo to reduce readmission rates.

How Healthcare Technology, the Coordination of Care, and the Use of Community Resources Can Address The Problem

Healthcare Technology

A growing body of evidence suggests that health care technology can play a role in preventing readmissions among ethnically diverse patients to hospitals with chronic conditions. One study found that the use of an electronic medical record (EMR) system was associated with a reduction in readmissions for black and Hispanic patients with congestive heart failure (CHF) (Elysee et al., 2021). Another study found that a computerized provider order entry (CPOE) system was associated with reducing readmissions for black and Hispanic patients with diabetes (Golden et al., 2017). In general, modern health care technologies may substantially improve the quality of care delivery for patients regardless of their ethnicity.

To effectively prevent readmissions among ethnically diverse patients, hospitals need to tailor their care coordination efforts to the specific needs of these populations. One way to do this is to use health care technology to facilitate communication between providers and patients (Warchol et al., 2019). For example, hospitals can use EMR systems to remind providers about upcoming appointments and patients about their medications. They can also use CPOE systems to ensure that providers make an appropriate decision in relation to a patient’s care delivery on the basis of the urgency and severity of his health condition and order the correct medications (Lyoons et al., 2017). By using health care technology to improve communication and coordination, hospitals can significantly reduce readmissions among ethnically diverse patients.

Coordination of Care

There is no one-size-fits-all answer to this question, as the coordination of care that prevents readmissions among ethnically diverse patients to hospitals with chronic conditions will vary depending on the specific needs of the patient population. However, some general strategies that may be effective in preventing readmissions among this population include improving communication between providers and patients, health care providers’ cultural competence in relation to ethnically diverse patients, the reduction of socioeconomic barriers to care, increasing patient education, and increasing coordination between primary care and specialty care providers. Making such changes in any healthcare facility guarantees quality health care to patients, reducing the chance of readmission.

Improving communication between providers and patients is important to prevent readmissions among ethnically diverse patients to hospitals with chronic conditions. This communication should include clear and concise information about the patient’s condition, treatment plan, and expectations for follow-up care. In addition, patients should be engaged in their care and involved in decision-making about their treatment. This can help to ensure that they understand their condition and are more likely to adhere to their treatment plan. Finally, it is important to coordinate care between primary care and specialty care providers (CMS, 2020). This coordination can help ensure that patients receive the care they need on time and that their concern is coordinated across the respective providers.

Community Resources

Although, there are no common guidelines, some ways that community resources could be applied to prevent readmissions among ethnically diverse patients to hospitals with chronic conditions include:

  • Establishing community health worker programs specifically targeted at reducing readmissions among ethnically diverse patient populations;
  • Creating educational materials and programs on chronic disease self-management for ethnically diverse patients (Regis College, 2018);
  • Working with local community organizations to increase access to transportation and housing for ethnically diverse patients with chronic conditions;
  • Implementing culturally-competent care coordination programs to ensure that ethnically diverse patients receive the continuity of care they need to prevent readmissions.

In general, care coordination needs to be tailored to the specific needs of each hospital and patient population. Providing culturally competent care ensures that all care team members are aware of and sensitive to their patient’s cultural backgrounds. It also involves providing culturally relevant education and resources to patients and their families for the improvement of communication and coordination between the hospital and patient’s primary care providers. This includes ensuring that all members of the care team are aware of the discharge plan and that there is a clear plan for follow-up care after discharge. Providing social support services may involve connecting patients with community resources or providing support services such as transportation or home health care and monitoring patients after discharge (Spatz et al., 2020). This includes ensuring patients take their medications as prescribed and follow up with their primary care providers as recommended.

Report on Experiences During the Practicum

During the two hours with patients trying to determine patient issues associated with health care technology, coordination of care, and use of community resources in preventing their readmission, I visited African Americans, Indians, and Caucasians. The patients were of varying ages, from 5 years to 70 years old. I aimed to assess their health condition and emotional wellbeing to evaluate the quality of health care delivery and initiate changes if necessary.

In general, patient visitation regarding healthcare technology issues had positive outcomes. Patients reported feeling more comfortable and informed when they could interact with their healthcare providers and ask questions about specific healthcare technology issues. They felt that they could better understand their condition and the available treatments when they could have this type of interaction. The response aligns with evidence-based practice studies, which reveal that patients interact with healthcare technology in various ways Golden et al., 2017). They can use technology to access their medical records, make appointments, and communicate with their care team. In addition, patients are using technology to track their health data, monitor their condition, and make decisions about their care. Hence allowing patients the leeway to use technology will foster self-care, which will, in turn, reduce readmission rates.

The patients had a lot to say about the issues surrounding coordination of care regarding reducing readmission rates. Some of the issues were the following:

  • Patients not being aware of or understanding their discharge instructions;
  • Patients not having a follow-up appointment scheduled with their primary care provider;
  • Patients not having medications available to them after discharge;
  • Patients not having transportation to and from follow-up appointments;
  • Patients not being able to afford medications or follow-up care.

Most evidence-based research points to the above issues as the leading causes of readmission. According to Brunner-La Rocca et al. (2020), one of the major causes of readmission is patients not having medication available. This leads to a chronic variation of a particular condition, necessitating readmission. In addition to other causes of readmission, patients must have support groups that could include family members and friends who assist them in managing their condition once they are discharged from the hospital.

Patients may be reluctant to utilize community resources due to a lack of trust or familiarity with the organizations. Additionally, patients may not be aware of the resources available to them, or they may have transportation or financial barriers that prevent them from accessing these services. Social workers can help patients navigate the process of finding and accessing community resources. They can also provide education on how to use these resources and follow up with patients to ensure they are using them effectively. In addition, social workers can help patients develop a plan to prevent readmission to the hospital. This may include identifying community resources that can provide support after discharge, such as home health services or transportation assistance. Social workers can also help patients develop a support system of friends or family members who can assist in discharge.

The plan of visiting patients and getting their perspective on issues they face that lead to admission led me to change how I deliver patient care. From my experience as a medical practitioner, I realized providing care beyond the hospital’s walls was necessary to prevent or reduce readmission rates. As such, I work closely with social workers and care homes. Social workers help provide transport for patients during hospital visitation. The care home provides specialized care for patients suffering from chronic illnesses or serious injuries. These hopes could provide physiotherapy, kidney dialysis, or emotional therapy for mentally ill patients.

What surprised me most during my two-hour interaction with patients was how eager they were to be included in their treatment process. Patients wanted to know the treatment regimen available for them and be directly involved in the treatment process. In addition, patients wanted the chance to choose the treatment method they deserved. Through this, they could participate actively, increasing the chances of the treatment working, reducing the chances of readmission. The practice aligns with several medical studies which agree that involving patients directly in the treatment process reduces readmission rates.

Individual Example

One of the patients with whom I communicated during my visit was Mr. Frank Koome, a 70-years-old African American adult who was diagnosed with hypertension a decade ago. His current health condition and the quality of his life were negatively impacted by obesity, stroke, coronary artery disease, alcoholism, substance misuse, and chronic cigarette smoking. When Mr. Koome’s hypertension had been diagnosed, he received information on this issue, however, he has not followed the advice provided to him. In addition, he admitted that he did not check his blood pressure regularly and before taking medication. Moreover, he sometimes forgot to take his prescription as well.

First of all, I decided to discuss the risks of hypertension and the ignorance of treatment with Mr. Koome one more time but in a culturally appropriate and respectful way. In other words, I expressed my understanding related to the patient’s age and habits that could appear due to challenging life circumstances. In addition, I mentioned that he had the right to make decisions concerning his health independently, however, it is my responsibility to inform him about potential complications. I felt that Mr. Koome appreciated this approach and were ready to listen to me attentively. Later, we discussed potential alternatives for the improvement of his self-regulation of hypertension. In particular, I recommended him to use a mobile app for the self-management of his condition. To be precise, I emphasized the ability of this app to remind him about the time of taking medicine to avoid its miss and the necessity to check blood pressure in advance. The patient was highly satisfied with this affordable option and thanked me for my assistance.


Overall, hospital readmissions increase the burden of disease on patients and are also expensive to the healthcare system. Fortunately, readmissions are preventable by utilizing available resources such as healthcare technology, community resources, and care coordination. For instance, using an electronic medical record (EMR) system was associated with a reduction in readmissions for black and Hispanic patients with congestive heart failure. Similarly, utilizing community resources such as care home reduces the disease burden, which reduces readmission rates. Despite using the available resources to reduce readmission, the healthcare system should invest in patient education to prevent and reduce readmission rates.


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Brunner-La Rocca, H.-P., Peden, C. J., Soong, J., Holman, P. A., Bogdanovskaya, M., & Barclay, L. (2020). Reasons for readmission after hospital discharge in patients with chronic diseases—Information from an international dataset. PLOS ONE, 15(6), e0233457.

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Spatz, E. S., Bernheim, S. M., Horwitz, L. I., & Herrin, J. (2020). Community factors and hospital wide readmission rates: Does context matter? PLOS ONE, 15(10), e0240222.

Warchol, S. J., Monestime, J. P., Mayer, R. W., & Chien, W.-W. (2019). Strategies to reduce hospital readmission rates in a non-Medicaid-expansion state. Perspectives in Health Information Management, 16. Web.

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