Background: Being healthy, feeling in control, and staying out of the hospital are outcomes strongly valued by patients. However, hospital readmissions remain high, especially among African-Americans and patients of minority-serving institutions (MSIs). MSIs provide care for many patients with limited social support and health literacy, who contribute to high readmission rates. Patients’ interests converge with those of hospitals now that, as part of quality improvement (QI) initiatives, the CMS has imposed financial penalties to hospitals with high 30-day readmission rates. Thus, MSIs may be at higher risk to be affected by CMS penalties and will benefit from improving patients’ outcomes and reducing readmissions. Classically, QI efforts focus on clinical interventions, and patients/caregivers have not played a major role in the development of QI efforts. In a novel approach to improve patients’ outcomes, we started engaging patients and caregivers at an MSI. They conveyed feelings of abandonment, anxiety/fear, and inadequate self-efficacy during transition from the hospital and expressed great interest in educational and social support, provided during home visits by a community health worker (CHW), as well as the need for telephone-based social/peer support.
Objectives: We propose to engage stakeholder groups at an MSI, including patients/caregivers, in an iterative process to develop a CHW-based Patient Navigator (CHW-Navigator) toolkit tailored to their needs to augment the benefits of a QI program to reduce readmission. We will compare the effectiveness of an integrated CHW-Navigator on the patient experience, 30-day readmissions rates, and other outcomes.
Methods: Using stakeholder focus groups (patients/caregivers, clinicians, hospital administrators, representatives of SHM BOOST), we will design a program that includes:
- a CHW patient navigator, supported by hospital-based clinicians (social worker, nurses, physicians), for in-person visits during hospitalization and a post-discharge home visit, to provide social support and literacy-appropriate self-management skills training and
- a patient/caregiver peer-led information line for ongoing telephone-based peer support, in collaboration with a patient advocacy group.
We will pilot test the program and modify the intervention based on results and on stakeholders’ input. We will then conduct a randomized clinical trial (~1,100 patients) to study the effects of the CHW-Navigator program on patients’ experience, self-management, and functional status and on readmission rates.
Importance: This timely program has the potential to greatly impact MSIs’ QI efforts, by tailoring to the needs of the patients they serve. The CHW-Navigator toolkit will be integrated in the resources available to hospitals implementing SHM's BOOST, ensuring rapid diffusion and scalability.
In Care Transitions, a Chance to Make or Break Patients' Recovery - A narrative on what happens when patients are harmed by poorly executed transitions between healthcare settings.