An intervention program that paired community health workers with patients led to a drop in 30-day hospital readmissions, according to clinical trial results published May 20 in JAMA Network Open.
The study, led by researchers at Boston-based Massachusetts General Hospital, involved 550 patients with accountable care insurance who were hospitalized between April 2017 and March 2019. The mean age of participants was 70.1 years, and all of the participants had a mean of three hospitalizations in the year before.
Of the 550 participants, about half received usual care, while the other half received the 30-day community health worker intervention along with usual care. As part of the intervention program, trained community health workers set out to strengthen patient connections to primary care, provided patients with health coaching services, and connected them to low-cost or free resources for things such as food and transportation.
Overall, 12.6 percent of those in the intervention group were readmitted to the hospital within 30 days after discharge, compared to 24.5 percent of those who didn't receive the intervention. Those who received the intervention were also less likely to miss clinic appointments in the 30 days after discharge.
Further analysis showed intervention participants discharged to short-term rehabilitation benefited the most, as opposed to those who were discharged directly home. Among those discharged to rehabilitation, researchers observed a 32.3 percent drop in 30-day readmission among the study cohorts, compared to a 5.7 percent reduction among those discharged home.
The significant benefit seen among those discharged to rehabilitation "may be that [community health workers] addressed unmet medical and social needs that occurred during the transition from rehabilitation to home and that CHWs improved communication among the patient, rehabilitation staff, and primary physician prior to return home," researchers said.