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Community Health Workers can Reduce Hospital Readmission Rates

By Stephen Tweed  Ask Stephen Tweed

How well are you doing connecting with hospitals to get referrals for your private pay home care business?

For two years, we’ve been talking about the Medicare Hospital Readmission Reduction Program, and the need for hospitals to find new ways to keep discharged patients from returning within 30 days.  We’ve told you that the three biggest factors in readmission are:

  1. Medication Compliance – getting patients to take their meds.
  2. Physician Follow Up – getting patients to keep their doctor’s appointments.
  3. Falls – while not directly related to the original diagnosis, patients are often subject to falls at home due to the effects of being hospitalized.

All three of these are issues that we can affect in home care.  There’s no one better to get patient to take their meds and keep their doctor appointments than an in-home caregiver.  Who better to clean up the house and remove clutter and loose carpets to prevent falls?

New Research Validates Our Concept

A new project at the University of Maryland St. Joseph Medical Center shows that deploying “Community Health Workers” to high-risk patients can reduce readmission rates significantly.  In May of 2016, 10% of high-risk patients were readmitted within 30 days compared to 25% in February 2015 when the project was launched. This project is a partnership between the hospital and Maxim Healthcare, a home care and staffing company based in Baltimore.

What’s a Community Health Worker?

A community health worker is a para-professional who is trained to visit patients frequently during the first 30 days after discharge.  Maxim began using CNAs in this role, but has expanded the qualifications to include EMTs and Certified Home Health Aides.  The Community Health Worker learn some basic clinical skills, and then focus on “motivational interviewing”.  This is a technique that involves engagement and empathy to build trust with the patient so they can identify any changes in condition that would require a visit by a nurse or a trip to the doctor’s office.

The research shows that patients face a wide variety of challenges during the first 30 days after discharge.  This may include getting prescriptions filled, making sure they are eating properly, and doing some straightening up around the house to remove clutter and prevent falls.

How Home Care Agencies can offer Community Health Workers

Most home care companies have someone on staff who works closely with clients and families to coordinate care.  This person may be a Geriatric Care Manager, Care Coordinator, or Senior Advocate.  Most agencies provide care management or care coordination as part of their hourly home care service package.  Many agencies provide care management and care coordination on a fee for service basis to families who need to “rent-a-daughter.”

We have a number of home care agencies that are members of our Home Care Mastermind Groups who have collaborated to create a “Hospital to Home Transition” program.  Either the hospital or the family pays the agency to transport the patient home, get them settled, fill prescriptions, and do grocery shopping.

What if this service were expanded to offer hospitals a “Community Health Worker” program that would make regular visits to patients during the first 30 days after discharge?

Would insurance companies, Medicare Advantage plans, and Managed Medicaid companies be willing to pay for this service to reduce hospital readmissions?

How much revenue could that create?

What would a program like this do to build relationships with hospital leaders and discharge planners?

How many additional private pay referrals might you get from a program like this?

We’d love your thoughts on this.


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