Readmissions are a thorn in the side of many a healthcare provider. They're problematic for patients because they increase their costs and overall headache, and they're a bane to healthcare organizations because of federal penalties affecting reimbursement based on 30-day readmission metrics.
To cut down on readmissions, some providers are taking a more proactive approach, looking at addressing social determinants of health -- those socioeconomic factors, such as as income level and access to transportation, that often determine how much a person needs medical care.
Partnering with community health workers to help monitor a patient's health post-discharge is one means of achieving that, and to that end, the University of Maryland St. Joseph's Medical Center has entered into a partnership with Maxim Healthcare Services. The goal? To target social determinants in the manner that's best for both the carers and the cared-for.
About four years ago, Maxim approach St. Joseph's with the concept of identifying patients who were at high risk for readmission based more on socioeconomic and psychosocial factors than their specific clinical issues. Tapping the expertise of community health workers was an important component of this approach.
"Using data from the nursing assessment, we were able to identify patients who were at high risk of readmission based on these psychosocial factors," said Dr. Gail Cunningham, St. Joseph's chief medical officer.
As part of the program, community health workers go to a patient's home and help them address some of their pressing needs. Some patients, for instance, may not have a legal ID card, or require transportation to a doctor's office. Some may not have a mattress to sleep on, a barrier to health if ever there was one.
"Community health workers are trained in behavioral motivation skills, so patients can think about their wellness differently," Cunningham said. "Hopefully by the end of 30 days, there are things in place to keep the patient out of the hospital."
While the overall philosophy places more emphasis on social determinants of health, it doesn't come at the expense of addressing the health concern itself. Rather, the two have to exist side-by-side.
"When you're addressing those issues, the patients who are being attended to have some complex medical conditions as well," Cunningham said. "But the fact that we're using more social determinants has resulted in very good progress in reducing readmissions.
"There's evidence that if you don't have transportation or a mattress on your floor, and you're worried about your basic fundamental needs, your health issues become secondary. We've learned more and more that it's very, very important."
Exactly how effective has the program been in curbing readmissions? At St. Joseph's, they're down by half. And spending is down 35 percent.
Still, it's sometimes challenging to convince a patient to let a community health worker monitor them for 30 days. Some patients are open to it from the word "go," while some are uncomfortable with the prospect of letting a health professional into their home. Others will initially decline the program, but then make it home and realize their health isn't quite as robust as they thought.
Whatever the scenario, the community health workers -- who are dispatched by Maxim -- need to be matched up well.
"As we look at the referrals that come over, it's really important to find folks who will be able to identify with the patients they're caring for, whether it's the background they come from, the neighbor they live in, and things like that," said Andy Friedell, Maxim's senior vice president of strategic solutions.
Because of that, Maxim has started recruiting community health workers from a wide array of diverse backgrounds. Empathy is the name of the game. These professionals have to be able to walk a mile in someone else's shoes.
One interesting result of the program is that it has relieved some of the pressure on physicians, who often lack the time and resources to address social determinants of health. Anecdotally, St. Joseph's staff has expressed relief at being eased of certain burdens, such as making sure the patient gets appropriate follow-up.
In Maryland, information about the patient can easily be shared between physicians and community health workers because of Chesapeake Regional Information System for our Patients, or CRISP, a portal to which the state's providers are connected. All of the information regarding patients -- when they presented to the hospital, what procedures they've had, their cost of care -- goes into that central repository of data.
"Maryland hospitals have a global budget model," said Friedell. "Outside of Maryland, oftentimes it's the payer who would be more interested in driving programs like this."
Whether payer or provider though, there's growing recognition, both inside Maryland and outside, that addressing social determinants of health is hugely important not only for patient health but for providers' pocketbooks.
Cunningham expects the program to continue to grow and mature.
"We're always trying to tweak it a little bit to see if we can further drive patient engagement," she said. "I think we're continuing to evolve."