Effect of Community Health Workers on 30-Day Hospital Readmissions in an Accountable Care Organization Population

Carter, Jocelyn; Hassan, Susan; Walton, Anne; Yu, Liyang; Donelan, Karen; Thorndike, Anne N.

doi:10.1001/jamanetworkopen.2021.10936

Cited by 21 publications

(55 citation statements)

References 44 publications

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“…Recognizing the amplified needs of patients without COVID-19 during the pandemic, the C-CAT team slowed new patient enrollment, and instead focused its efforts on reconnecting with previously enrolled Medicaid patients to offer COVID-related safety information and assistance in addressing outstanding clinical and social needs. 9…”

Section: Introductionmentioning

confidence: 99%

Meeting the Needs of Vulnerable Primary Care Patients Without COVID-19 Infections During the Pandemic: Observations From a Community Health Worker Lens

Carter

Hassan

Walton

2022

J Prim Care Community Health

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Background: During the height of the COVID-19 pandemic, healthcare systems were forced to focus their efforts on the rapidly rising numbers of patients contracting COVID-19. Although a myriad of publications focused on COVID-19 care have rapidly emerged, few have studied the impact of the pandemic on care received by patients without COVID-19. Objectives: To identify the experiences of Medicaid patients without COVID-19 related illness during the pandemic through the lens of community health worker outreach. Methods: From July 15, 2020 through February 1, 2021 patients previously enrolled in the C-CAT initiative were contacted by telephone for patient check-ins by CHW staff. Results: A total of 24 patients were contacted telephonically. Six patients had no active needs. Of the remaining patients, 70% of participants indicated that they had been unable to communicate with PCP or physician specialist care teams since the beginning of the pandemic and requested assistance from our CHW. Resulting unmet needs included the inability to obtain prescriptions drugs, necessary medical equipment, or supplies. Conclusion: The shift to COVID-19 focused care during the pandemic limited access to primary care for patients without COVID-19. The identified unmet patient needs included obtaining prescription medications, acute on chronic clinical condition management, healthcare services at home, and connection to social services. CHWs are uniquely positioned to assist patients as they connect to necessary clinical care, whether it be virtual or in-person, as they recover from the pandemic experience.

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Section: Introductionmentioning

confidence: 99%

Meeting the Needs of Vulnerable Primary Care Patients Without COVID-19 Infections During the Pandemic: Observations From a Community Health Worker Lens

Carter

Hassan

Walton

2022

J Prim Care Community Health

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“…The evidence for CHW care is demonstrated in studies among chronic disease and cardiovascular populations. 10 - 13 …”

Section: Discussionmentioning

confidence: 99%

“… 8 , 9 and interventions focused on closing gaps related to social determinants of health have both shown promise as independent interventions. 10 - 12 However, both home-based and digital platform interventions face limitations of scale and technical constraints, respectively. Home-based interventions are generally labor intensive often making it difficult to prioritize care for patients without contacting them directly, a time-consuming process.…”

Section: Introductionmentioning

confidence: 99%

Patient Perspectives on Home-Based Care and Remote Monitoring in Heart Failure: A Qualitative Study

Carter

Donelan

Thorndike

2022

J Prim Care Community Health

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Introduction: As individual interventions, home-based care and remote monitoring have been shown to help prevent hospitalizations for those with heart failure (HF) although both interventions have been limited by scalability and technical constraints, respectively. Few qualitative studies have explored patient perspectives, including acceptability, barriers, and facilitators of HF care inclusive of both interventions. The objective of this study is to explore patient perceptions on HF management at home, the use of home-based remote monitoring, and the value of home-based care. Methods: Qualitative interviews (N = 27) were conducted via phone (12/2020-3/2021) with adults with HF. A framework analysis was used to identify main themes along with verbatim transcription for coding and analyses. There were 5 key interview domains: general HF knowledge, perceptions of the value of home-based care, unmet needs related to the social determinants of health (SDOH), experience with healthcare technology and remote monitoring, and challenges in HF home management. Results: Five major themes emerged. Patients reported: (1) home-based care plan instructions are understood; (2) following medication, diet, and fluid management instructions are challenging due to difficult adherence to and implementation at home; (3) financial limitations serve as barriers to acquiring healthy food; (4) home-based support is a valuable component of managing medications, diet, and fluid; (5) despite limited use of technology, strong willingness to use remote monitoring is present amongst most. Conclusions: Participants reported understanding of care plan instructions and challenges adhering to care plans at home. Barriers included needing more home-based support for medications, diet, and fluid management and requiring additional assistance with financial barriers related to unmet social needs. A combined intervention inclusive of remote monitoring and home-based support has potential to improve home-based strategies and clinical outcomes for HF patients.

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“…https://www.picf.org/ (accessed on March 15, 2021). 6 Rush University Medical Center. Social Work and Community Health Services.…”

Section: Recruitment Processmentioning

confidence: 99%

“…These public health workers often share a sociocultural background with the patients in the communities they serve, which allows them to establish trust and improve the health system's ability to provide higher quality and culturally appropriate care (3). Evidence shows that CHW/P interventions can improve health outcomes for marginalized communities by increasing access to primary care, improving behavioral health, reducing the likelihood of 30-day hospital readmissions, supporting chronic disease management, and lowering hospitalization rates (4)(5)(6)(7).…”

Section: Introductionmentioning

confidence: 99%

Adding a Seat at the Table: A Case Study of the Provider's Perspective on Integrating Community Health Workers at Provider Practices in California

C¹,

Durazo²,

Purry³

et al. 2021

Front. Public Health

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Blue Shield of California's Community Health Advocate Program was created to support whole person-health needs by helping individuals of all socio-economic statuses navigate and access community resources, social services, and medical systems. Blue Shield's Health Reimagined team is partnering with medical providers, community resources centers, and community partners to provide intensive person-centered and technology-enabled care to patients, ensuring social needs are met while promoting health equity. A key aspect of the Health Reimagined initiative embeds Community Health Advocates (CHAs) within physician practices serving patients using a payor-agnostic approach, by which Blue Shield aims to increase access to social services and community resources, improve health outcomes, reduce medical costs, and improve overall patient experience. The purpose of this case study is to understand the provider's perspective of embedding a CHA into the care team and the resulting impact on the practice and patients. Blue Shield also sought to identify best practices and barriers of a CHA program within primary and specialty care practices. As part of an ongoing two-year mixed-methods impact evaluation (2019–2021), 10 semi-structured interviews were conducted with a total of 18 providers and office staff at five primary care and specialty practices where CHAs have been embedded. We also conducted two focus groups with the same five CHAs at different points in time. Several themes emerged from the provider, office staff, and CHA interviews. Provider practices found great value in adding a CHA to their care team as the CHA brings flexibility and continuity to patient care. They also found that having access to a CHA with shared life experiences of the communities they served is a key component to the program's success. Providers and staff reported a new understanding of the social determinants of health that impacts a patient's wellbeing with the embedding of a CHA in the care team. Overall, practitioners expressed high satisfaction with the CHA program. During the COVID-19 pandemic, CHAs have been critically important in care, as social needs have increased, and resources have shifted. The CHA program is constantly adapting to address challenges faced by all stakeholders and applying new knowledge to ensure best practices are implemented within the CHA program.

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Effect of Community Health Workers on 30-Day Hospital Readmissions in an Accountable Care Organization Population

Cited by 21 publications

References 44 publications

Meeting the Needs of Vulnerable Primary Care Patients Without COVID-19 Infections During the Pandemic: Observations From a Community Health Worker Lens

Meeting the Needs of Vulnerable Primary Care Patients Without COVID-19 Infections During the Pandemic: Observations From a Community Health Worker Lens

Patient Perspectives on Home-Based Care and Remote Monitoring in Heart Failure: A Qualitative Study

Adding a Seat at the Table: A Case Study of the Provider's Perspective on Integrating Community Health Workers at Provider Practices in California

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