An integrated model of care utilizing community health workers to promote safe transitions of care.

BACKGROUND/OBJECTIVES: Healthcare systems' adoption and sustenance of successful transitional care models (TCMs) have been limited by cost-prohibitive resource needs. Cost-effective TCMs that improve patient outcomes are needed to promote adoption by healthcare systems and sustainability. This study evaluated the effectiveness of a TCM utilizing community health workers (CHWs) in reducing inappropriate healthcare utilization and costs. DESIGN: A cohort study with a pre-post intervention evaluation of the intervention group. SETTING: A 953-bed academic urban safety-net hospital. PARTICIPANTS: Eligible participants (N = 154) were hospitalized or had repeated emergency room (ER) visits, identified to be at high risk for readmission. INTERVENTION: Promotion of self-management skills acquisition and care coordination by CHWs achieved through predischarge interdisciplinary team meetings, regular home visits and phone contact, accompaniment to primary care physicians' (PCP) appointments, support with transportation, medications, and self-management education. MEASUREMENTS: Outcome measures were readmissions, ER visits, and PCP establishment. RESULTS: Mean age of participants was 67, 65% were male, 92% African American. There was a significant reduction in overall number of readmissions (Z = 9.6, p < 0.001), also observed at 30-day (Z = 5.5, p < 0.001), 3-month (Z = 4.3, p < 0.001), 6-month (Z = 4.0, p = 0.001), and 1-year (Z = 5.4, p < 0.001) post-intervention. There was a significant reduction in the overall number of ER visits (Z = 5.5, p < 0.001), also seen at 3-month (Z = 3.3, p < 0.001), 6-month (Z = 3.0, p < 0.001), and 1-year (Z = 4.0, p < 0.001) intervals. Care with a PCP was established in 86.6% of participants. Utilization costs were significantly lower post-intervention ($11,530,376.39 vs $4,017,493.17, p < 0.001). CONCLUSION: Use of CHWs during transitions of care may be a cost-effective approach to reducing healthcare utilization and costs and may promote adoption and sustainability within healthcare systems.

Towards Patient Safety: Evaluation of Care Transitions Training Needs Among Key Providers Involved in Patient Care Transitions.

Significant morbidity, mortality, and increased healthcare costs of up to 20.1 billion dollars annually occur as a result of poorly executed patient care transitions. The critical role of providers in ensuring patient safety at discharge requires provider knowledge of required care transitions processes to ensure optimal execution of transitions of care. The present study was designed to determine provider perception of their care transitions training, curriculum content, and self-identified care transitions knowledge gaps. A cross-sectional survey was conducted among key healthcare providers at the Grady Memorial Hospital, a 953 bed urban safety net hospital. Of these, 131 participants completed the surveys including 73 internal medicine residents, 51 nurses, and 7 social workers. Among participants, 13% reported that they had never had any formal training on care transitions. Of these, 88.2% were medical residents, while 11.8% were bedside nurses. Among participants who had received care transitions training, only 40% received their training prior to graduation. Healthcare providers across disciplines were least exposed to training on discharge settings of care, determining the most appropriate next level of care for patients at discharge, and communication and coordination with post-acute care facilities. Providers made recommendations regarding topics they considered important to be included in care transitions training. Defining the full discharge process and responsibilities of various healthcare providers were topics recommended by most providers as important to be included in care transitions training. This study has highlighted the extent of exposure to formal care transitions training among providers from multiple disciplines involved in various aspects of discharge care. It has demonstrated a paucity of formal care transitions training at the health professional school level. It has also highlighted self-identified care transitions training needs and will form a foundation for design of care transitions curricula for a broad range of healthcare professionals.

Implementation of a care transitions model for low-income older adults: a high-risk, vulnerable population.

Low-income older adults are particularly vulnerable during care transitions. The present study evaluated the effectiveness of a transitional care model in this population. A quasi-experimental design was used to compare outcomes in the intervention group with historical controls at 30, 90, 180, and 365 days after discharge, along with a pre-postintervention evaluation of the intervention group. Eligible individuals were age 60 and older hospitalized between June 2008 and January 2009. Main outcome measures were readmissions, emergency department (ED) visits, and primary care services use. Of 121 participants, 55% were female and 90% African American, with a mean age of 69. Readmission rates were generally but not significantly lower in the intervention group than in controls (Day 30, 9.6% vs 17.3%; Day 90, 28.9% vs 25.0%; Day 180, 32.7% vs 36.5%; Day 365, 44.2% vs 53.9%; P > .05), as were ED visit rates (Day 30, 17.3% vs 15.4%; Day 90, 32.7% vs 34.6%; Day 180, 38.5% vs 40.4%; Day 365, 50.0% vs 55.8%; P > .05). Primary care service utilization rates were significantly higher in the intervention group than in controls at Day 30 (40.4% vs 19.2%, P < .001), 90 (74.9% vs 32.7%, P < .001), and 180 (65.4% vs 32.7%, P < .001). The lack of statistically significant reduction in readmissions and ED visits with the intervention, may suggest the need for additional assistance during care transitions for this vulnerable population.