Community health worker support reduces 30-day readmission among high-risk ACO patients

A photo of a community health worker wearing a mask
Thirty-day readmissions were down among high-risk ACO patients supported by trained community health workers, Massachusetts General Hospital researchers wrote in a recent study. (Getty/Kemal Yildirim)

Pairing community health workers with adult inpatients under accountable care organization insurance coverage reduced readmissions and missed appointments with outpatient providers during the first 30 days of discharge, according to a recently published Massachusetts General Hospital study.

While these trends were greater among patients who were discharged to short-term rehabilitation, a subgroup analysis found that the difference in readmission was no longer significant among those who were directly discharged to their homes.

Still, the data lend support to policies supporting insurance-based reimbursement for and investment in community health worker services targeting high-risk patients, the researchers wrote.

“While inpatients discharged to rehabilitation prior to transitioning home have been identified as high-risk for 30-day readmission, little research has been done to determine effective interventions to reduce readmissions,” they wrote in JAMA Network Open. “Results from our post hoc analyses demonstrated that [community health workers] are a promising intervention for this population, but future studies are needed to confirm these findings.”

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The clinical trial included data from 550 participants who were hospitalized between April 2017 and March 2019 and considered to be at high risk for hospital readmission.

On average, the participants were 70 years old and had three hospitalizations within the prior year. The researchers randomized 273 of these patients to the control group and 277 to the intervention group.

The study’s community health workers received a month of training on core competencies—such as motivational interviewing, goal setting and psychosocial support—and met with intervention group patients and inpatient teams prior to discharge. Once patients left the hospital, the workers delivered health coaching and other support through phone calls, texts and in-person visits.

After 30 days, significantly more patients in the control group were readmitted than those in the intervention group (24.5% versus 12.6%). Missed appointments were also more common among those without community health worker support (33.7% versus 22%), although emergency department visits were statistically similar.

A subgroup analysis of the cohort looking at patients discharged to rehabilitation found a 32.3 percentage point reduction in admissions among those with the intervention. A similar analysis among those discharged to their homes found readmission rate differences between the study groups to be insignificant.

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The researchers noted that their study was conducted at a single urban hospital among ACO-insured patients living nearby, and as such may not be generalizable to a broader population.

Psychosocial support and reinforcement of adherence to care plans were the most frequent services delivered by the workers, the researchers wrote.

With these support services, the workers were able to drive readmission rate improvements even when compared to controls enrolled in “comprehensive” case management or nursing programs as a result of their coverage under an ACO, they wrote.

“This difference highlights CHW capacity to address gaps in care related to unmet psychosocial needs (eg, securing meal delivery, transportation, access to medications, elder care services, accompaniment to clinic visits),” the researchers wrote. “[Community health workers] can add value to the ACO model in a large health care organization by better connecting patients to community resources and programs as well as primary and subspecialty clinical homes.”