An integrated model of care utilizing community health workers to promote safe transitions of care.
J Am Geriatr Soc
; 69(9): 2638-2647, 2021 09.
Article
in En
| MEDLINE
| ID: mdl-34287819
ABSTRACT
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.Key words
Full text:
1
Collection:
01-internacional
Database:
MEDLINE
Main subject:
Models, Organizational
/
Community Health Workers
/
Transitional Care
Type of study:
Etiology_studies
/
Incidence_studies
/
Observational_studies
/
Prognostic_studies
/
Risk_factors_studies
Limits:
Aged
/
Female
/
Humans
/
Male
Language:
En
Journal:
J Am Geriatr Soc
Year:
2021
Document type:
Article
Affiliation country:
Estados Unidos