Background: In 2011, ~3.3 million adult 30-day US hospital readmissions generated $41.3 billion in hospital costs. $8.26 billion (20%) of this was considered preventable. Numerous studies demonstrate relationships between hospital readmissions and social determinants of health (SDoH). Lack of education, socioeconomic status, and lack of social support have all been cited as core contributors to readmission rates. Data from our previous Massachusetts General Hospital (MGH) Department of Medicine (DOM) readmissions study showed that < 45% of readmitted patients have reading skills expected for basic interpretation of prescription labels and 22% are within 250% of the federal poverty level. Despite emphasis on clinical best practice and safety-net programming, MGH 30- day readmission rates remain sub-optimal at ~17.1% in 2018. This intervention focuses on a novel and narrowly studied process of implementing community health workers (CHWs) into care teams for the first 30 days after hospital discharge. Despite strong evidence demonstrating the efficacy of hospital-based CHWs in reducing readmissions, this is the first MGH intervention of this kind.
Methods: Inpatient adults meeting criteria (ACO patients, with a PCP, not on hospice care, with >=1 hospitalization in the prior 3 months or >=2 hospitalizations in the prior year) and hospitalized on one of six internal medicine inpatient study units (4/2017-3/2019) were consented and randomized to enrollment via block randomization to usual care with or without the CHW 30-day intervention. All participants completed a pre-enrollment questionnaire/needs assessment (domains included patient-perceived confidence in taking care of themselves after discharge, understanding of their care plan, barriers to care, and gaps related to social determinants of health domains) and a post-enrollment questionnaire. CHW used enrollment questionnaires with patient for the 30-day interval prior to discharge. CHWs documented patient communication/encounters in the electronic health record. For the 30-day CHW intervention, CHWs utilized methods of motivational interviewing, goal-setting, and psychosocial support for patients while gathering input from clinical care team members. CHW care was delivered by performing home visits, arriving at patient homes in a hired car to accompany them to a clinic visit, or even assisting with the completion of insurance applications. CHWs connected patients with low/no-cost services to augment transportation, food access, housing, or other domains driving gaps in care while fostering patient connections to care teams.
Results: Preliminary data for 350 participants demonstrated 45% lower readmissions, 51% less emergency room visits, and 38% less missed post-discharge appointments as compared to controls. Finalized data for 550 participants is pending and expected 2/1/2020.
Conclusions: The application of a peri-discharge CHW intervention demonstrated clear reduction in 30-day hospital readmissions for a vulnerable ACO population at risk for readmission. Implementation of this kind of intervention should be considered to enhance best practice for high-risk medical populations.