A program that uses community health workers to help chronically ill patients access care following hospitalization has cut readmission rates in half and reduced hospital spending by 35 percent for high-risk patients, according to an analysis from Maryland providers.
The University of Maryland St. Joseph Medical Center (UMSJMC) and Maxim Healthcare Services collected data from a program that uses community health workers to help patients at high risk for hospital readmission due to medical, psychological, functional and socioeconomic complexity.
Patients enrolled in the program are assigned a community health worker who is specially trained to address issues such as transportation, housing, employment and access to medical services that are often barriers to care following discharge.
Over a three-month period, researchers followed 1,778 patients who were identified during their hospitalization as being at high risk for readmission. Of that group, 840 patients enrolled in the program and used community health worker services, while 938 did not enroll or did not respond to outreach following discharge from UMSJMC. Data provided by Maryland's health information exchange was also analyzed to establish visit and hospital charge information across all Maryland hospitals.
Data collected in 2017 and the first half of 2018 shows only 8 percent of program participants were readmitted to the hospital within 30 days of discharge compared with 18 percent of non-program participants.
Only 23 percent of program participants returned to the hospital within 90 days post-discharge compared with 34 percent of non-program participants. Over a two-year period, the reduction in readmissions represents more than $3 million in savings and a 3.8:1 return on investment.
“The work we're doing to support patients dealing with complex medical issues and unmanaged psychological or social challenges is not only beneficial for our patients, but also for the healthcare system as a whole,” said Gail Cunningham, M.D., senior vice president and chief medical officer at UMSJMC, in a prepared statement.
Maxim and UMSJMC also evaluated the program's financial impact by comparing per-patient hospital charges in the months before and after program enrollment. Participants continued to generate lower hospital charges after the 30-day program was complete. Per-patient charges for participants decreased by 35 percent after 30 days and by 9 percent after 90 days. At the same time, non-program participants saw pre- to post-discharge charges decrease by 4 percent after 30 days and actually increase by 12 percent at 90 days.
"The key to the success of this program is a strong focus on the social and behavioral barriers that keep many patients from adhering to their clinical plans," explained Andy Friedell, Maxim's senior vice president of strategic solutions, in a statement. "Through the use of community health workers, we are able to help high-risk patients transition back to their homes without heightening their risk for readmission. The benefits of this approach come into even sharper focus when you consider that a full year of this type of community-based program is less expensive than an average 27-day stay in a skilled nursing facility and roughly half the cost of the average readmission."
