Within 30 days of discharge, 20 percent of fee-for-service Medicare patients are readmitted to the hospital. The frequency of readmission for Medicare patients costs the nation an estimated $17 billion annually, but research suggests 75 percent of these readmission cases are preventable.
The University of Kentucky Department of Family and Community Medicine, in partnership with St. Claire Regional Medical Center in Morehead, Kentucky, and Kentucky HomePlace recently launched a pilot study to evaluate the impact community health workers have in reducing hospital readmission rates. Using a multidisciplinary model of transitional care, the one-year study will attempt to reduce 30-day readmission rates for high-risk hospital patients in Eastern Kentucky.
The study's goals include assessing the 30-day readmission risk during client intake; addressing psychosocial and health determinants of high-risk patients before and after discharge through assistance from a community health worker; and monitoring the impact of the community health worker intervention based on measures such as compliance with discharge orders, follow-up appointments and readmission rates.
According to Dr. Roberto Cardarelli, chief of Community Medicine in the UK Department of Family and Community Medicine and principal investigator for the study, a range of socioeconomic and personal factors influence hospital readmission rates. Personal circumstances influencing readmission include accessibility to community health providers, unstable living environments, costs of medication, lack of transportation, and failure to comply with discharge orders.
Preceding research on hospital readmission reduction programs indicates a patient navigator, such as a community health worker, can improve the patient's quality of life and health outcomes, consequently reducing 30-day readmission rates. While the study is based in Appalachia, Cardarelli said its findings could have implications for both rural and urban settings.
"Nobody is usually looking into these social aspects," Cardarelli said. "Why did the patient not pick up their medicine? Well, it's because they have no money. Those subtle things are often overlooked but can make a big impact."
Lay community health workers, who will receive training from Kentucky HomePlace, will act as a link between discharged patients and local health care services. In the first four to six months of the study, community health workers will collect baseline data from high-risk readmission patients at St. Claire Regional Medical Center. The workers will conduct patient wellness needs assessments to measures risks such as depression, health literacy, adherence and compliance risks, support, social factors and financial barriers to care. They will follow-up with patients four weeks after discharge to review the client's status.
In the second phase of the program, community health workers will intervene with follow-up care for consenting patients discharged from the hospital. After conducting the wellness needs assessment, they will work individually with patients to develop a client-centered care plan. Post-discharge, the health workers will monitor the patient's progress with reminders for follow-up visits and assistance accessing community health resources.
"Essentially they will navigate patients to identify social barriers," Cardarelli said of the community health workers. "They will help address and find community resources, and contact patients to see how they are doing, if they are making their follow-up appointments."
UK Family and Community Medicine and St. Claire Regional Medical Center launched the program last fall. The study is supported by a grant from PassPort Health Insurance company and is in partnership with St. Claire Regional Medical Center and Kentucky Homeplace in the Center for Excellence in Rural Health, which has provided community health workers in 27 Eastern Kentucky counties for the past 20 years.
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