Patients with low socioeconomic status (SES) use more acute hospital care and less primary care than patients with high socioeconomic status. This low-value pattern of care use is harmful to these patients' health and costly to the health care system. Many current policy initiatives, such as the creation of accountable care organizations, aim to improve both health outcomes and the cost-effectiveness of health services. Achieving those goals requires understanding what drives lowvalue health care use. We conducted qualitative interviews with forty urban low-SES patients to explore why they prefer to use hospital care. They perceive it as less expensive, more accessible, and of higher quality than ambulatory care. Efforts that focus solely on improving the quality of hospital care to reduce readmissions could, paradoxically, increase hospital use. Two different profile types emerged from our research. Patients in Profile A (five or more acute care episodes in six months) reported social dysfunction and disability. Those in Profile B (fewer than five acute care episodes in six months) reported social stability but found accessing ambulatory care to be difficult. Interventions to improve outcomes and values need to take these differences into account. R educing avoidable hospitalizations and emergency department (ED) visits is a major target for cost control and quality improvement in the health care system. Hospitalizations for ambulatory care-sensitive conditions 1 -that is, acute conditions that could have been prevented or mitigated by effective ambulatory care 2 -cost approximately $30.8 billion annually.3 At each stage of care, patients with low socioeconomic status (SES) are at higher risk for being hospitalized for ambulatory care-sensitive conditions than patients of higher socioeconomic status.1-7 Low-SES patients are twice as likely as high-SES patients to require urgent ED visits, 4,8 four times more likely to require admission to the hospital, 1-3 and more likely to return to the hospital after discharge 6,7,9,10 and require multiple hospitalizations for any given illness.11 At the same time, they use 45 percent less ambulatory 12 and preventive care 13,14 than high-SES patients. Un-and underinsurance drive low-SES patients' preferential use of inpatient health services in part. 1,[15][16][17][18] But even in countries with near-universal health insurance coverage, lowvalue use persists among low-SES patients. 19This suggests that factors beyond insurance shape preferences for inpatient versus ambulatory care.The relative underuse of primary care and overuse of hospital-based care among low-SES patients, which we call "low-value use," has two negative consequences. First, these patients are less likely to gain the health benefits of primary care, 20,21 exacerbating health disparities.

IMPORTANCE Socioeconomic and behavioral factors can negatively influence posthospital outcomes among patients of low socioeconomic status (SES). Traditional hospital personnel often lack the time, skills, and community linkages required to address these factors.OBJECTIVE To determine whether a tailored community health worker (CHW) intervention would improve posthospital outcomes among low-SES patients. DESIGN, SETTING, AND PARTICIPANTSA 2-armed, single-blind, randomized clinical trial was conducted between April 10, 2011, and October 30, 2012, at 2 urban, academically affiliated hospitals. Of 683 eligible general medical inpatients (ie, low-income, uninsured, or Medicaid) that we screened, 237 individuals (34.7%) declined to participate. The remaining 446 patients (65.3%) were enrolled and randomly assigned to study arms. Nearly equal percentages of control and intervention group patients completed the follow-up interview (86.6% vs 86.9%).INTERVENTIONS During hospital admission, CHWs worked with patients to create individualized action plans for achieving patients' stated goals for recovery. The CHWs provided support tailored to patient goals for a minimum of 2 weeks. MAIN OUTCOMES AND MEASURESThe prespecified primary outcome was completion of primary care follow-up within 14 days of discharge. Prespecified secondary outcomes were quality of discharge communication, self-rated health, satisfaction, patient activation, medication adherence, and 30-day readmission rates.RESULTS Using intention-to-treat analysis, we found that intervention patients were more likely to obtain timely posthospital primary care (60.0% vs 47.9%; P = .02; adjusted odds ratio [OR], 1.52; 95% CI, 1.03-2.23), to report high-quality discharge communication (91.3% vs 78.7%; P = .002; adjusted OR, 2.94; 95% CI, 1.5-5.8), and to show greater improvements in mental health (6.7 vs 4.5; P = .02) and patient activation (3.4 vs 1.6; P = .05). There were no significant differences between groups in physical health, satisfaction with medical care, or medication adherence. Similar proportions of patients in both arms experienced at least one 30-day readmission; however, intervention patients were less likely to have multiple 30-day readmissions (2.3% vs 5.5%; P = .08; adjusted OR, 0.40; 95% CI, 0.14-1.06). Among the subgroup of 63 readmitted patients, recurrent readmission was reduced from 40.0% vs 15.2% (P = .03; adjusted OR, 0.27; 95% CI, 0.08-0.89). CONCLUSIONS AND RELEVANCEPatient-centered CHW intervention improves access to primary care and quality of discharge while controlling recurrent readmissions in a high-risk population. Health systems may leverage the CHW workforce to improve posthospital outcomes by addressing behavioral and socioeconomic drivers of disease. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01346462

Background Compared to whites, African Americans have a greater incidence of diabetes, decreased control, and higher rates of micro-vascular complications. A peer mentorship model could be a scalable approach to improving control in this population and reducing disparities in diabetic outcomes. Objective To determine whether peer mentors or financial incentives are superior to usual care in helping African American Veterans improve their glycosylated hemoglobin (HbA1c) levels. Design A six month randomized controlled trial. (ClinicalTrials.gov registration number: NCT01125956) Setting The Philadelphia VA Medical Center. Patients African American veterans, age 50-70 years old, with persistently poor diabetes control. Measurements Change in HbA1c at 6 months Intervention 118 participants were randomized to one of the three arms. Usual care participants were notified of their starting HbA1c and recommended goals for HbA1c. Those in the peer mentor arm were assigned a peer mentor who formerly had poor glycemic control but now had good control (HbA1c < 7.5%) who was asked to talk with the participant at least once a week. Peer mentors were matched on race, sex, and age. Those in the financial incentive arm could earn $100 by dropping their HbA1c by one point and $200 by dropping it by two points or to a HbA1c of 6.5%. Results Mentors and mentees talked the most in the first month (mean calls 4: range 0-30) and dropped to a mean of 2 calls (range 0-10) by the sixth month. HbA1c dropped from 9.9% to 9.8% in the control arm, 9.8% to 8.7% in the peer mentor arm and from 9.5% to 9.1% in the financial incentive arm. Mean change in HbA1c from baseline to 6 months relative to control was −1.07 (95% CI −1.84 to −0.31) in the peer mentor arm and −0.45 (95% CI −1.23 to 0.32) in the financial incentive arm. Limitations The study included only veterans and lasted only 6 months. Conclusions Peer mentorship improved glucose control in a cohort of African American Veterans with diabetes.

IMPORTANCE Addressing the social determinants of health has been difficult for health systems to operationalize. OBJECTIVE To assess a standardized intervention, Individualized Management for Patient-Centered Targets (IMPaCT), delivered by community health workers (CHWs) across 3 health systems. DESIGN, SETTING, AND PARTICIPANTS This 2-armed, single-blind, multicenter randomized clinical trial recruited patients from 3 primary care facilities in Philadelphia, Pennsylvania, between January 28, 2015, and March 28, 2016. Patients who resided in a high-poverty zip code, were uninsured or publicly insured, and who had a diagnosis for 2 or more chronic diseases were recruited, and patients were randomized to either the CHW intervention or the control arm (goal setting only). Follow-up assessments were conducted at 6 and 9 months after enrollment. Data were analyzed using an intention-to-treat approach from June 2017 to March 2018. INTERVENTION Participants set a chronic disease management goal with their primary care physician; those randomized to the CHW intervention received 6 months of tailored support. MAIN OUTCOMES AND MEASURES The primary outcome was change in self-rated physical health. The secondary outcomes were self-rated mental health, chronic disease control, patient activation, patient-reported quality of primary care, and all-cause hospitalization. RESULTS Of the 592 participants, 370 (62.5%) were female, with a mean (SD) age of 52.6 (11.1) years. Participants in both arms had similar improvements in self-rated physical health (mean [SD], 1.8 [11.2] vs 1.6 [9.9]; P = .89). Patients in the intervention group were more likely to report the highest quality of care (odds ratio [OR], 1.8; 95% CI, 1.4-2.4; risk difference [RD], 0.12; P < .001) and spent fewer total days in the hospital at 6 months (155 days vs 345 days; absolute event rate reduction, 69%) and 9 months (300 days vs 471 days; absolute event rate reduction, 65%). This reduction was driven by a shorter average length of stay (difference, −3.1 days; 95% CI, −6.33 to 0.22; P = .06) and a lower mean number of hospitalizations (difference, −0.3; 95% CI, −0.6 to 0.0; P = .07) among patients who were hospitalized. Patients in the intervention group had a lower odds of repeat hospitalizations (OR, 0.4; 95% CI, 0.2-0.9; RD, −0.24; P = .02), including 30-day readmissions (OR, 0.3; 95% CI, 0.1-0.9; RD, −0.17; P = .04). CONCLUSIONS AND RELEVANCE A standardized intervention did not improve self-rated health but did improve the patient-perceived quality of care while reducing hospitalizations, suggesting that health systems may use a standardized intervention to address the social determinants of health.