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 more active role in their health care. The program includes one hospital and one home visit, followed by a series of follow-up phone calls with a designated transition coach. This health coach is charged with helping patients improve disease self-management behaviors such as medication management, person health record keeping, and knowledge of health indicators that may warn of worsening conditions.

In Louisville, a collaborative project between Jewish Hospital and the Louisville Metro Department of Public Health & Wellness employed peer advisors in the Transitions of Care model in an effort to drive down readmissions. A peer adviser, who comes from a similar background as the patient, visits the patient’s home each week for four weeks following a hospital discharge. During these home visits, peer advisors may notice if a patient faces impediments to care, such as not having a car or a phone, and help address these issues. The peers work closely with and receive support from the clinical team; the project manager speaks with them on a daily basis and meets with them in person once a week.

Alice Bridges, VP of healthy communities for the Louisville market of Kentucky One Health, the parent company of Jewish Hospital, emphasizes that “The community health worker is a critical part of the model. When only the nurse is interacting with the patient, it’s not nearly as effective.”

The use of the peers has played an important role in the early success of the program. During the first 9 months of the program, the readmission rate for the 275 patients completing the program was 19.3 percent, which was 3.5 percentage points lower than the rate for non-program participants discharged from the same hospital. With these promising results, the program will be expanding to two additional hospitals and will focus on all “high utilizers” of hospitals, not just the uninsured or those on Medicaid.

The success of this program in Louisville adds to the evidence base for the Transitions of Care model. The model was also highlighted by the American Academy of Family Physicians in a case study on health coaching. The AAFP notes, “The low cost of this model allows for adoption in a wide variety of settings, and the investment in coaching pays dividends downstream in reduced health care costs.” With the increased financial pressure for hospitals to reduce readmissions to hospitals, there may now be an even greater need for the use of peer supporters and community health workers in care transition programs.

In the push to reduce readmission rates, hospitals across the country are experimenting with different care transition models. In New York, the Bronx Collaborate recently finished a study with 3 non-profit hospitals that employed nurses in patient care transition. In this study, “nurse care transition managers had four possible interventions to use with patients: (1) a pre-discharge educational session with the patient; (2) a post-discharge call within 48-72 hours of discharge to make sure that a follow-up visit with the patient’s physician was scheduled; (3) a phone call between 7-14 days to make sure the patient had actually gone to the appointment; and (4) calls between 15-60 days post-discharge just to check on the patient.” Of 500 patients who received at least two of these interventions, 17.6 percent were readmitted within 60 days, compared to 26.3 percent who didn’t receive any intervention.

These studies collectively show that care transition programs can utilize a variety of health service workers, often in similar roles. Additional research is needed to help determine what kind of health care workers can most effectively provide these services to patients. Furthermore, with greater costs associated with using nurses and physicians for some of these transition tasks compared to peer supporters and community health workers, understanding the roles each kind of worker can perform is increasingly important.

Know of a successful care transition model using peer supporters? Peers for Progress invites you to share your stories with our network.