Abstract
<h3>Background</h3> Chronically ill adults insured by Medicaid experience health inequities following hospitalisation. <h3>Local problem</h3> Postacute outcomes, including rates of 30-day readmissions and postacute emergency department (ED), were higher among Medicaid-insured individuals compared with commercially insured individuals and social needs were inconsistently addressed. <h3>Methods</h3> An interdisciplinary team introduced a clinical pathway called ‘THRIVE’ to provide postacute wrap-around services for individuals insured by Medicaid. <h3>Intervention</h3> Enrolment into the THRIVE clinical pathway occurred during hospitalisation and multidisciplinary services were deployed into homes within 48 hours of discharge to address clinical and social needs. <h3>Results</h3> Compared with those not enrolled in THRIVE (n=437), individuals who participated in the THRIVE clinical pathway (n=42) experienced fewer readmissions (14.3% vs 28.4%) and ED visits (14.3% vs 28.8 %). <h3>Conclusion</h3> THRIVE is a promising clinical pathway that increases access to ambulatory care after discharge and may reduce readmissions and ED visits.
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