A transitional care model utilizing community health workers significantly reduced overall readmissions (p<0.001) and ER visits (p<0.001) compared to pre-intervention levels.
Cohort (n=154)
No
Does a transitional care model utilizing community health workers reduce healthcare utilization and costs in patients at high risk for readmission?
A transitional care model utilizing community health workers significantly reduced readmissions, ER visits, and healthcare costs in high-risk patients.
p-value: p=<0.001
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.
Ohuabunwa et al. (Mon,) conducted a cohort in High risk for readmission (n=154). Transitional care model utilizing community health workers vs. Pre-intervention was evaluated on Readmissions, ER visits, and PCP establishment (p=<0.001). A transitional care model utilizing community health workers significantly reduced overall readmissions (p<0.001) and ER visits (p<0.001) compared to pre-intervention levels.
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