Preventable Hospitalizations


        Preventable Hospitalizations is a measure of how many patients utilize the hosptial as a result of preventable conditions which could have been prevented through  early intervention and outpatient care. This can be an important measure of a community's access to health care. Access to health care is an important challenge for the United States and Tennessee. 


        When community members do not seek medical care for common conditions, those conditions can worsen over time to the point of requiring costly hospitalizations. Improved access to primary care would both lower medical care costs for those at risk of preventable hospitalization and provide people with more accessible treatment and maintenance of helath conditions before they require hospitalization. 


        Reserach shows that low-income populations, patients aged 65 and older, non-Hispanic blacks, and Hispanics have the highest rates of preventable hospitalizations, indicating a potential lack of primary care access. These disparities in access to care can be traced back to rates of chronic disease management, inadequate access to care, care coordination, lower quality of care, health literacy and language barriers, transportation to care, insurance coverage, and stable and safe housing. 

Vital Sign Actions Guide

The following are lists of intervention strategies that you, your health council, and other local stakeholders could use to address access to health care in your community.  


1. Accountable Care Community 

he Centers for Medicare and Medicaid Services supports 31 Accountable Health Communities across the U.S. The Accountable Health Community Model brings together clinical services and social services to serve the physical, mental, and social needs of individuals in the healthcare setting. The coordination of providers brings together organizations that provide aid for housing, food, utility bills, and transportation. Currently, Ballad Health (East TN) is the only participating Accountable Care Community in Tennessee. 


2. Adult Literacy Classes 

Literacy is an important indicator of short- and long-term health outcomes. In particular, literacy skills affect an individual’s degree of health literacy. Health literacy is crucial to properly following instructions provided by a healthcare provider, taking medications as prescribed and understanding health conditions. Consider partnering with adult literacy programs in your county to support family literacy or start an adult literacy program if your county doesn’t already have one. 


3. Broadband Access

Low-income neighborhoods, particularly in low-density rural geographies, are often disproportionately disadvantaged by a lack of broadband access. Without adequate internet access, low-income families are restricted in telemedicine, education, participation in the online economy, and employment among other disadvantages. Major barriers to broadband access include price and physical equipment.  Expanding access to neighborhoods in need of broadband may include purchasing equipment, community classes on how to use digital equipment, or subscription subsidies. 


4. Community Paramedicine

Community paramedicine programs expand the role of paramedics and emergency medicals technicians (EMTs) to include public health and primary care services. By expanding these roles, access to care is improved and non-emergency use of emergency services is decreased. Click on the link for more information on what community paramedicine is and how to start a program in a rural community. 


5. English Language Program 

Families who aren’t proficient in the English language are disadvantaged in several ways—lower educational attainment, poor health and decreased health literacy, and limited employment opportunities. Health literacy is crucial to properly following instructions provided by a healthcare provider, taking medications as prescribed and understanding health conditions. Consider working with healthcare providers, schools, and employers to market existing English language classes for youth and adults. 


6. Evidence-Based Home Visiting 

Evidence Based Home Visiting (EBHV) programs are an early intervention strategy that aims to improve health outcomes for children in their first years of life. These programs improve family functioning and parenting skills, link families to social services, promote early learning, and help new parents provide safe, nurturing environments for their infants. In Tennessee, there are eleven EBHV local implementing agencies funded by the Tennessee Department of Health that operate in 51 counties, in addition to the CHANT program that operates in all health departments. These home visiting services can help to reduce household risks and ensure adherence to prescriptions. 


7. Homebuyer Education

Safe and adequate housing is crucial to preventing avoidable hospitalizations. Patients who suffer from unstable housing conditions are less able to adhere to diet and prescription medication regimens that are an important part of managing chronic diseases such as diabetes and heart disease. Research shows that individuals who attend a homebuyer’s education course are significantly less likely to lose their homes to foreclosure than those who don’t attend a course. Offering homebuyer education courses in community settings such as colleges and universities, large employers, faith-based organizations, and family community centers (e.g. YMCA) can increase the proportion of individuals and families who are prepared to buy a home and help them avoid foreclosure in the future. 


8. Increasing Access to Transportation 

Adequate access to transportation can affect an individual’s employment, healthcare, and education, among other essential services. Programming that increases access to transportation in rural areas can come in a variety of models—public transit, volunteer drivers, coordinated services, ridesharing, etc. There are also ways in which a community can mitigate the effects of lack of transportation, such as mobile health clinics and telehealth, active transportation infrastructure, and home visiting. See the source for a list of promising practices. 


9. Palliative Care Program 

Palliative care is similar to other home health and hospice services in that it provides care for complex and long-term conditions. These programs offer clinical services including home visits, case management by an interdisciplinary care team, chronic disease management, conversations regarding care goals, and other interventions. This type of care significantly reduces hospital readmissions particularly for patients with chronic diseases and complex comorbidities.  


10. Remote Area Medical 

Remote Area Medical (RAM) is a nonprofit provider of free mobile health clinics. RAM provides free dental, vision, and medical services to underserved and uninsured individuals. Services are free and do not require ID from patients. Communities that lack health care services can request a mobile RAM clinic event. See the source for a list of services provided by RAM and a clinic schedule. 


11. School-Based Healthcare 

School-based Health Centers (SBHC) increase access to primary care for children in school settings. The services provided by SBHCs can include primary care, mental and behavioral health care, dental care, health education, and case management. Schools can partner with local health organizations to provide services to students. Additionally, these services may be provided as telehealth services to schools that aren’t able to partner directly with a local healthcare organization. 


12. Telehealth 

The Health Resources and Services Administration supports the expansion of telehealth in improving access to and coordination of care delivery. Telehealth is especially critical in rural and other remote areas that lack sufficient health care services, including specialty care. This type of healthcare can include video conferencing, internet resources, imaging and media streaming, and other communication technology. Telehealth is particularly important in rural communities that face challenges with geography and transportation to clinical services. 


1. Appalachian Regional Commission 

Purpose: Grants and funding are awarded by the Appalachian Regional Commission (ARC) focusing on economic opportunities, ready workforce, critical infrastructure, natural and cultural assets, and leadership and community capacity. Tennessee (Eastern Appalachian region) is among 12 other states that are eligible to receive funding from ARC.

Duration: Varies 

Amount: Up to $4,000,000; Varies 


2. Community Development Block Grant 

Purpose: The Community Development Block Grant (CDBG) Entitlement Program provides annual grants on a formula basis to entitled cities and counties to develop viable urban communities by providing decent housing and a suitable living environment, and by expanding economic opportunities, principally for low- and moderate-income persons. The U.S. Department of Housing and Urban Development (HUD) awards these grants to entitlement community grantees to carry out a wide range of community development activities directed toward revitalizing neighborhoods, economic development, and providing improved community facilities and services.

Duration: 1 to 3 years 

Amount: Up to $1,500,000; Varies 


3. Community Foundations

Purpose: Community Foundations offer small grants that focus on community-driven change in Tennessee. The Community Foundations in Tennessee include Appalachian Community Fund, The Community Foundation of Greater Chattanooga, Community Foundation of Greater Memphis, Community Foundation of Middle Tennessee, Knox County Community Foundation, and East Tennessee Foundation. Most of these foundations consider community development as a focus area of grant funding.

Duration: Varies 

Amount: Varies 


4. Delta Regional Community Health Systems Development Program Technical Assistance 

Purpose: The Delta Regional Authority provides grant funding for communities along the lower Mississippi River Delta, including 21 counties in West Tennessee and works to create inclusive communities, develop long-term economic development, and produce meaningful opportunities for residents in the Delta counties. This grant provides technical assistance to healthcare organizations and communities to improve health systems over time. Funded initiatives include quality improvement, workforce recruitment and retention, telemedicine, Emergency Medical Services access, care coordination, and social determinants of health programming. 

Duration: Varies 

Amount: Technical Assistance 


5. Dollar General Literacy Foundation 

Purpose: The Dollar General Literacy Foundation supports literacy initiatives through grant funding in several priority areas. Funded areas include implementing or expanding literacy programs, purchasing technology or equipment, purchasing books or materials for literacy programs, and summer literacy programs for Pre-K through 12th grade students who are below grade level reading or who have learning disabilities. The foundation also supports family literacy programs. 

Duration: Varies 

Amount: Up to $3,000 (summer reading); Up to $15,000 (family literacy) 


6. Rural Transportation Grant Program 

Purpose: The Rural Health Information Hub recommends increasing access to transportation as a way to address health in rural communities. Transportation is crucial to adequate access to primary care. See the RHIhub site below for a list of funding sources that a county may consider to fund “transportation to support rural healthcare” initiatives. 

Duration: Varies 

Amount: Varies 


7. Telehealth Network Grant Program 

Purpose: The Health Resources and Services Administration (HRSA) support telehealth initiatives for medically underserved populations. The goals of this grant program are to expand access to, coordinate, and improve the quality of healthcare services, expand training, and improve the quality of health information.  HRSA also supports the Substance Abuse Treatment Telehealth Network Grant Program and the Evidence-Based Tele-Behavioral Health Network Program to increase access to mental health and substance abuse services. 

Duration: Varies 

Amount: Varies 


8. Tennessee Center for Health Workforce Development (Community Incentive Grant) 

Purpose: The Community Incentive grant is administered by the Tennessee Center for Health Workforce Development to provide funding for underserved, rural hospitals and recruit healthcare professionals. This grant can be used for signing bonuses, technology, relocation expenses, and loan repayment, among other things. Eligible hospitals must serve at least 30% TennCare or uninsured patients. 

Duration: One year

Amount: $30,000


9. The HCA Foundation

Purpose: The HCA Foundation promotes health and wellbeing, childhood and youth development, and the arts in middle Tennessee communities through grant funding administration. Organizations must be 501(c)3 nonprofits in the Middle Tennessee area (see the website for eligible counties) to apply. 

Duration: Varies 

Amount: Varies 


10. Transportation Alternative Program (TDOT)

Purpose: The Tennessee Department of Transportation awards grants annually to communities for projects that improve access and provide a better quality of life for Tennesseans by increasing access to alternate modes of transportation. Grants must be applied for through local planning organizations. Projects may include management of sidewalks, bike lanes, abandoned railways, scenic overlooks, and other activities to improve access. Additionally, the Tennessee Department of Transportation funds cities and counties that fall outside of an MPO planning boundary in order to develop community transportation plans for future transportation systems, land use, and growth management. 

Duration: $250,000 - $1,000,000 (general); up to $125,000 (transportation planning)

Amount: 1 year 


11. U.S. Department of Education Grants 

Purpose: The U.S. Department of Education offers several competitive grants that aim to improve early literacy. These grants include Innovative Approaches to Literacy Programs and Striving Readers Comprehensive Literacy. The US Department of Education also funds the 21st Century Community Learning Centers grants, a program that awards funding through the Tennessee Department of Education to establish or support community learning centers. These learning centers provide educational support and youth development activities during after-school hours and breaks. Among other activities, the grant funding can be used for academic enrichment, remedial education, limited English proficient classes, expanded library hours, family literacy, and tutoring programs. 

Duration: Three years (21st Century Grant)

Amount: $50,000+ (21st Century Grant)


1. National Healthy Homes Month 

National Healthy Homes Month is celebrated in June, and seeks to raise awareness about home quality and safety. The safety and quality of housing for an individual plays an important role in overall health and wellbeing. This month can be used to educate the public on the topic of environmental justice and health disparities as they relate to healthy homes. Click on the link for a calendar of events and social media resources.  


2. Promote Safety Net Clinics

Charitable care clinics and safety net clinics provide care at little to no cost to qualifying low-income or uninsured individuals. These clinics help to expand access to limited primary care such as preventive care, physicals, reproductive health care, and treatment or certain medical conditions. For a list of safety net clinics and charitable care clinics, click on the link. 


3. Promote TN Housing Development Agency (THDA) Services 

The Tennessee Housing Development Agency serves Tennesseans by working to increase and retain the amount of affordable housing for low-income residents. Housing is a crucial element to preventing avoidable hospitalizations and promoting management of chronic diseases. Programs with THDA focus on expanding and supporting homeownership through providing new affordable housing, financial assistance, and supporting the rehabilitation of existing affordable housing. Promoting programs such as the Great Choice Home Loans, Down Payment Assistance, and Homebuyer Education can help community members afford to be homeowners in their own communities.


4. Promote TN State Loan Repayment Program & J-1 Visa

The Tennessee State Loan Repayment Program (TSLRP) recruits health professionals to rural communities that qualify as Health Professional Shortage Areas (HSPA) by offering educational loan repayment in exchange for two years of service. Health professions that are eligible for the TSLRP program include Primary Care Physicians, dentists, Advanced Practice Nurses, Physician Assistants, and Mental Health Professionals. Similarly, the J-1 Visa program sponsors individuals in exchange for provision of health services in underserved Tennessee communities. Promoting these programs to recent graduates in health professional fields may increase access to quality care in HPSA Tennessee communities. 


1. Zoning Policies to Increase Walkability and Connectivity 

Access to primary care can often be limited by poor walkability in a community. Several factors can lead to safer, more walkable routes including proper sidewalks and lighting, lower speed limits for adjacent traffic, shade to mediate warmer weather, and adequate pedestrian signage. These zoning policies are particularly important for low-income residents without alternate modes of transportation to access primary care. 


1. Always Use Teach Back Framework 

Healthcare providers can combat low levels of health literacy by using the Teach Back method. This method ensures that healthcare providers speak clearly and understandably to patients. Patients or caregivers are then asked to explain in their own words any instructions given by the provider.  The Teach Back framework increases a patient’s understanding and adherence to instructions given by the healthcare provider. 


2. Care Coordination 

The Care Coordination Task Force, supported by the American Nurses Association and the American Academy of Nursing, recommends policies to encourage nurse-led care coordination in the clinical setting. The task force recommends policies to support payment for care coordination services and implementation of care coordination measures. Coordination of care in the clinical setting is crucial to chronic disease management, social determinants of health, and medication adherence. 


3. Policies to Reduce Avoidable Rehospitalizations 

The institute for Healthcare Improvement published a how-to guide for healthcare providers to be able to reduce avoidable hospital readmissions. This guide focuses on transitions from in-patient hospital care to home or community care settings. Examples of recommended changes include comprehensive needs assessment of the patient, patient education, Teach Back techniques, incorporation of a follow-up plan, and post-hospital care instructions.  Click on the link for policy recommendations at the provider-level.


4. Screening for Social Determinants of Health and Referral to Services 

The primary drivers of poor health and hospital admissions are represented by social determinants of health (SDoH). In addition to coordination of care within the clinical setting, it is important that health care providers screen their patients for existing SDoH and refer patients in need to appropriate community services. Click on the link for sample SDoH questionnaires from the American Academy of Family Physicians. 


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