Accelerating Best Practices in Peer Support Around the World
3.20.14

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 Patient-Centered Targets (IMPaCT) is one CHW intervention described as a “standardized, exportable CHW model”. A recent article documents the findings of a randomized control trial to test the effect of IMPaCT on post-hospital outcomes among low-income patients on Medicaid or without insurance thirty days after hospital discharge.4 A process evaluation was also conducted to gauge patient satisfaction with CHWs.

IMPaCT Study and Intervention Design

The single-blind study took place at two hospitals in Philadelphia, PA. Patients were randomized into the intervention or control arm. Patients in the control arm received routine hospital care, which included daily multidisciplinary rounds to discuss patients’ discharge needs, medication reconciliation, and written discharge instructions and prescriptions. Primary care physicians received a discharge summary within 30 days of discharge. Patients in the intervention arm received routine care plus IMPaCT.

The primary outcome measure was primary care follow-up within 14 days of discharge. Secondary outcomes were quality of discharge communication, self-rated health, satisfaction, patient activation, medication adherence, and 30-day readmission rates.

The IMPaCT intervention was based on prior participatory action research that the researchers conducted with low-SES patients who had been hospitalized, in which they sought to understand the reasons for poor post-discharge outcomes based on patient perspectives.

The intervention is based on three elements:

Recruitment and hiring guidelines
Used traits that low-SES, high risk patients identified as important from qualitative interviews. There was a minimum educational requirement (high school diploma).

Training
A month-long course prepared CHWs to address barriers commonly reported by patients.

Standardized work practices
The IMPaCT protocol defines three stages of tailored care: goal setting, goal support, and primary care connection. Upon hospital admission, CHWs use a semi-structured interview guide with intervention patients, beginning the interview with: “What do you think you will need to do to stay healthy after discharge?” The CHW and patient worked together to make an individualized plan for achieving the patient’s goals. Each plan included a measureable goal, resources, and a step-by-step plan.

IMPaCT Increases Access to Post-Hospital Primary Care and Reduces Multiple Readmissions

Patients who received IMPaCT were significantly more likely to access post-hospital primary care and to report high-quality discharge communication. They also reported better mental health and patient activation. There were no significant differences between groups in physical health, satisfaction with medical care, or medication adherence. The difference in readmission rates within 30 days was not statistically significant. However, patients in the intervention arm were less likely to have multiple readmissions. Among patients who were readmitted, the intervention decreased recurrent readmissions.

Most (79.7%) intervention patients provided positive feedback. Patients appreciated that the intervention was tailored to their preferences. Patients described CHWs as highly accessible, helping them with problems “outside the box”. For example, to address social isolation, a CHW accompanied one patient to a local recreation center. Patients provided examples of instrumental (67.1%), emotional (19.3%), and informational (5.8%) social support provided by CHWs.

Negative feedback was reported by 12.1% of the patients. Some felt that CHW support was redundant because they already had social support; others felt that the CHW was too busy to provide adequate support; and several thought the intervention was too short.

A Standard Model That Can Be Adapted for Many Populations and Settings

This trial demonstrated that CHWs can improve patient experiences with care, improve access to primary care providers post-hospitalization and other patient outcomes, and improve discharge communication, mental health, and patient activation. Process evaluation showed that the majority of patients responded favorably to CHW support. Future studies are needed in diverse patient populations to see if the IMPaCT model can be adapted for CHW interventions that are effective in different patient populations and settings. This intervention was designed to be effective for patients regardless of diagnosis, making it replicable for a wide range of conditions.

The authors acknowledge the limitations of the brief intervention and ability to follow patients for longer than the study duration. However, demonstrating that a brief intervention can increase access to post-hospitalization primary care and lead to better outcomes is a very promising finding.

 

References

  1. Naylor, M. D., Aiken, L. H., Kurtzman, E. T., Olds, D. M., & Hirschman, K. B. (2011). The importance of transitional care in achieving health reform. Health Affairs, 30(4), 746-754.
  2. Misky, G. J., Wald, H. L., & Coleman, E. A. (2010). Post‐hospitalization transitions: Examining the effects of timing of primary care provider follow‐up. Journal of Hospital Medicine, 5(7), 392-397.
  3. Burt, C. W., McCaig, L. F., & Simon, A. E. (2008). Emergency department visits by persons recently discharged from US hospitals. US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics.
  4. Kangovi, S., Mitra, N., Grande, D., White, M. L., McCollum, S., Sellman, J., … & Long, J. A. (2014). Patient-Centered Community Health Worker Intervention to Improve Posthospital Outcomes: A Randomized Clinical Trial. JAMA internal medicine.
  5. Kangovi, S., Barg, F. K., Carter, T., Levy, K., Sellman, J., Long, J. A., & Grande, D. (2013). Challenges faced by patients with low socioeconomic status during the post-hospital transition. Journal of general internal medicine, 1-7.

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