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

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.

Community-informed, integrated, and coordinated care through a community-level model: A narrative synthesis on community hubs

“…11 The value of community-level models are gaining renewed interest among health system leaders and clinicians to support patients, their caregivers, and clinicians in improving their respective experiences in accessing and providing care, improving community and population health, and reducing healthcare expenditures. 17,18 In Ontario, Canada, the implementation of the Connecting Care Act, 2019 aims to improve access to care; integration and coordination of services; patient experience; and use of resources. 19 The health system transformations attributed to this legislation in Ontario resemble a community hub model of care, but a clear definition of which services and supports are provided in such a model requires a more in-depth investigation.…”

Community health workers and transitions of care

“…In this issue of JAGS, Ohuabunwa and colleagues describe a novel transitional care model targeting sufficient numbers of low-income and minority older adults to examine such if a novel transitional care model could reduce the frequency of repeated ED visits and hospitalizations. 1 A central feature of this model was to utilize highly trained Community Health Workers (CHWs) as agents of change. Each patient in the study was assigned a CHW for 12 months.…”