Lay-health workers reduced readmission rates at rural hospital, study finds
A new report from Health Education Research found lay-health workers (LHWs) that addressed social needs affected readmission rates for a high-risk population at a rural community hospital in Kentucky.
The study found a nearly 48% relative reduction of 30-day hospital readmissions for those in the program compared to patients that were not part of the program.
The researchers also discovered that simple regression analyses showed a 56% decrease in odds of the patients being readmitted within 30 days. When adjusted for education, transportation and anxiety symptoms, the researchers said there was a 77% decrease in odds of readmission for patients that were part of the LHW program.
Reducing readmissions can play a key financial role for providers who are increasingly being paid for reaching quality benchmarks in value-based models.
The study authors wrote LHWs “offer an effective hospital-based model to improve transitions in care from the hospital setting, especially those at high-risk with persistent social needs.”
The quasi-experimental study looked at how the LHW model helped high-risk patients post discharge. The researchers measured 30-day hospital readmission rates. They compared a four-month baseline period to a six-month post-implementation period.
The LHW project featured assessing and developing a personalized social needs plan for enrolled patients that included transportation and identifying community resources, as well as post-discharge follow-up calls.
The program is an example of a healthcare organization joining community workers to address population health factors, including social determinants of health (SDoH). These factors, such as food insecurity, housing instability and lack of transportation, can place barriers in front of people trying to improve their health.
If you’re not sure where you’re spending the night or how to get a doctor’s appointment, you’re less likely to adhere to medication or make regular appointments. That can lead to poor health, especially for patients with comorbidities.
Payers and providers are both working on the issue of SDoH. Dr. Sarika Aggarwal, chief medical officer at Beth Israel Deaconess Care Organization, recently told Healthcare Dive, “The key to population health is truly about taking care of patients across the care continuum ... I have not found a (population health management) program that hasn't helped the patient.”
More than 80% of payers said they are integrating SDoH into member programs, according to the 8th annual Industry Pulse survey. On the provider side, the American Hospital Association published a guide last year that showed how housing affects a community’s health with recommendations on how hospitals can assist. Both payers and providers, as well as community programs, need to work together to deliver the care, provide the analytics and care coordination, reimburse appropriately and offer programs that help patients beyond a doctor’s appointment.