Hospitalization
IMPaCT: A Scalable CHW Model to Reduce Hospital Readmissions among High-Risk Patients
Melissa Mayer
In health reform, preventing avoidable hospital readmissions after discharge is an important metric that reflects higher quality of care and leads to lower health care costs.1 Follow-up with a primary care provider is a significant predictor of 30-day hospital readmission rates; a recent study found that people who did not see a primary care provider post-hospitalization were 10 times more likely to be readmitted within thirty days of discharge.2 The rate of readmission after hospital discharge is much higher among people lacking health insurance; a report from the U.S. Department of Health and Human Services found that those without health insurance were three times as likely as people with private insurance to be readmitted.3
Health care providers are increasingly turning to community health workers (CHW) as a way to link patients with primary care and address patients’ social, behavioral, and economic barriers to accessing care. Individualized Management for…
Peer Supporters as Transition Coaches for Reducing Hospital Readmissions
Clayton Velicer, MPH
Starting in October 2012, the Affordable Care Act’s Hospital Readmissions Reduction Program began imposing financial penalties on hospitals with excess hospital readmissions for conditions such as acute myocardial infarction, heart failure, and pneumonia. Information on the measures and payment adjustment methodologies are available at the CMS website. Our previous blog discussed the potential role for community health workers and peer supporters in reducing hospital readmissions. In this blog, we’ll look at a care transition program that has successfully used peer supporters to coach patients after being discharged from the hospital.
The California Healthcare Foundation, a grant-making nonprofit based in Oakland, recently released an issue brief on two models being pilot tested for transitioning care from hospitals. One of these models, the Coleman Transitions of Care model, is a four-week process designed to empower and support patients to take a…
Reducing Hospital Readmissions through Peer Support Programs
Patrick Tang, MPH
A major challenge for the Affordable Care Act (ACA) is to reduce overall healthcare costs while improving quality of care. Based on recent studies, policymakers were convinced that reducing hospital readmissions was a feasible approach to achieve both of these goals. Through performance-based penalties, the ACA is taking an aggressive course to rapidly reduce excess hospital readmissions. This effort will require greater coordination of care and cooperation between hospital and community resources.
Peer support programs can improve transition of care, promote outpatient physician visits, reduce stress, provide social support, and share their experiences to help discharged patients avert preventable hospital readmissions. Several ACA provisions are expanding the role of community health workers, making them eligible for Medicare reimbursement as patient navigators and as part of multidisciplinary care teams. Hospitals can take advantage of these funding…
