Within 30 days of discharge, 20 percent of fee-for-service Medicare patients are readmitted to the hospital. The frequency of readmission of Medicare patients costs the nation an estimated $17 billion annually, but research suggest that 75 percent of these readmission cases are preventable.
The University of Kentucky (UK) Department of Family and Community Medicine http://familymedicine.med.uky.edu in partnership with the St. Claire Regional (SCR) Medical Center www.st-claire.org in Morehead, Kentucky and the Kentucky Homeplace http://ruralhealth.med.uky.edu/cerh-homeplace launched a pilot study last fall.
Grant support was provided by Passport Health Plan www.passporthealthplan.com to reduce the 30 day readmission rates for high risk hospital patients in Eastern Kentucky.
Kentucky Homeplace was developed by the University of Kentucky, Center for Excellence in Rural Health and is based in the eastern Kentucky coal mining town of Hazard as a demonstration project in 14 counties.
To cut readmission rates, lay community health workers will receive training from Kentucky Homeplace and will act as a link between discharged patients and local healthcare services. In the first four to six months of the study, community health workers will collect baseline data from high-risk readmission patients at the SCR Medical Center, a 159 bed regional referral center and the largest rural hospital in northeastern Kentucky.
The study will perform client intakes, determine psychosocial and health determinants for high risk patients before and after discharge with help from community health workers, and then monitor the impact of the community health worker intervention on readmissions.
Community health workers will also conduct patient wellness assessments to measure depression, health literacy, adherence and compliance risks, and examine social factors and financial barriers to care. Follow-up with the patients will take place four weeks after discharge to review the status of the patient.
During the second phase of the program, community health workers will intervene with follow-up care for consenting patients discharged from the hospital. After conducting the wellness needs assessment, they will work individually with patients to develop a client-centered care plan.