Deploying community health workers to reduce readmission rates

Maryland has the only all-payer hospital-rate regulation system in the country under a decades-old Medicare waiver. Since 1977, the state’s Health Services Cost Review Commission has set the prices hospitals charge patients, regardless of their insurance coverage.

The state has also been an outlier for another reason: its readmission rates. Historically, they were high compared to the rest of the country. In 2010, when 18.6% of Medicare patients in the U.S. were hospitalized again within 30 days of discharge, Maryland’s rate was 2.7 percentage points higher. In 2014, the Maryland commission and the CMS Innovation Center required Maryland hospitals to close that gap by 2018.

At the University of Maryland St. Joseph Medical Center, a 232-bed hospital in Towson, a quarter of highrisk patients were hospitalized again within 30 days. So the hospital began deploying community health workers tasked with helping these patients address pressing nonclinical issues after they leave the hospital.

“You cannot underestimate the importance of addressing the psychosocial needs of patients upon discharge,” said Dr. Gail Cunningham, St. Joseph’s chief medical officer. “The best medical plan in the world is going to fail if some of the patient’s basic needs aren’t met.”

In its first 16 months, readmission rates for patients enrolled in the program dropped by 60%. In May, about 10% of St Joseph’s high-risk patients were readmitted within 30 days, compared with 25% when the hospital launched the program in February 2015 in partnership with medical staffing company Maxim Healthcare.

To identify patients who are highly likely to be readmitted, a nurse practitioner interviews patients before discharge and verifies their risk level. Then, the nurse practitioner sets up a care plan with a registered nurse outside the hospital as well as a community health worker to figure out how to address the patient’s needs.

Within two days of discharge, the registered nurse goes to the home to ensure that the patient doesn’t have other unmet needs. They perform clinical assessments too.

But it is the community health worker who is especially critical. Patients experience a wide range of challenges after they leave the hospital. Some need help getting prescriptions or filling out job applications. Many lack family support at home and are prone to falling. Some suffer from dementia or addiction. Or they live in food deserts with limited access to nutritious food. In one case, a patient simply needed help get- ting a mattress. The community health workers can help meet those needs themselves or connect patients with other resources.

Over the course of 30 days, the community health worker visits a patient at home five to 10 times. The regularity of the visits means that the worker builds trust and a relationship with the patient.

The nurse practitioners, registered nurses and community health workers are all employed by Maxim. It was Maxim that approached St. Joseph, Cunningham said, to explore the idea of examining nonmedical factors that contribute to readmissions and using community health workers to reduce unnecessary returns.

Since the program’s launch, nurse practitioners have carried out some 1,600 assessments of high-risk patients; roughly 1,200 have opted into the program—about 5% of the patients the hospital discharges each year. From February 2015 to July 2016, St. Joseph used a total of 15 community health workers to look after about 1,200 patients. Six to 10 community health workers were employed at any given time.

Initially, Maxim focused on hiring certified nursing assistants as community health workers. But the company has begun to broaden the qualifications to include emergency medical technicians, home health aides and others with relevant backgrounds.

Maxim trains these workers in elements of both clinical and community health work, said Andy Friedell, a vice president at Maxim. For instance, they learn motivational interviewing, a technique for behavior change that involves engagement and empathy. They put in roughly 10,000 hours of work between February 2015 and May 2016, Friedell said.

St. Joseph plans to expand community health worker services to the behavioral health population, and Cunningham said she hoped the program ultimately will benefit all high-risk patients as more payers see the benefits for their budgets, and for patients.