The frequency of readmission for Medicare patients costs the nation an estimated $17 billion annually and research suggests that 75 percent of these readmission cases are preventable.
St. Claire Regional Medical Center (SCR) has partnered with the University of Kentucky (UK) Department of Family and Community Medicine, and Kentucky HomePlace to launch a pilot study to evaluate the influence community health workers have in reducing hospital readmission rates. The goal of this one year study is to decrease 30-day readmission rates for high-risk hospital patients in Eastern Kentucky.
The study's overall goals include assessing the 30-day readmission risk during client intake; addressing psychosocial and health determinants of high-risk patients before and after discharge through assistance from a community health worker; and monitoring the impact of the community health worker intervention based on measures such as compliance with discharge orders, follow-up appointments and readmission rates.
Lay community health workers, who will receive training from Kentucky Home Place, will act as a liaison between discharged patients and local health care services. In the first phase of the pilot study, community health workers will help identify any socioeconomic factors or social barriers collecting baseline data from high-risk readmission patients at SCR and then following up with them four weeks after discharge to review the client's status.
During the second phase of the program community health workers will work individually with patients to develop a client-centered care plan monitoring the patient's progress with reminders for follow-up visits and assistance accessing community health resources.
SCR and UK Family and Community Medicine were able to launch this program last fall by obtaining a grant from PassPort Health Insurance and furthermore from the support of Kentucky HomePlace, which has provided community health workers in 27 Eastern Kentucky counties for the past 20 years.