The Community CAre Transitions (C-CAT) clinical trial, which paired community health workers (CHWs) with patients admitted to Harvard-affiliated Massachusetts General Hospital (MGH), has found that fewer intervention group participants were readmitted within 30 days than control group participants. The effect was significant for those discharged to short-term rehabilitation but not for those discharged home. The study has been published in JAMA Network Open.
“These results indicate that CHW interventions may help reduce hospital readmissions and improve preventive care among some clinically complex patients within an accountable care organization,” says lead author and C-CAT trial principal investigator Jocelyn Carter, a physician-scientist in the MGH Division of General Internal Medicine.
Hospital readmissions have been identified as a major contributor to health care costs, accounting for a third of total U.S. health care expenditures. Thirty-day readmissions are common and about 27 percent of adult 30-day readmissions are estimated to be preventable. Previous studies have identified factors such as medical complexity and social determinants of health as contributing to readmission risk.
While community health workers are one of few interventions demonstrating compelling evidence of improving outcomes in clinically and socially complex populations, most CHW studies have focused on disease-based cohorts. The study of CHW interventions at the time of hospital discharge has been underutilized and prior trial results have been mixed.
In the C-CAT study, CHWs, trained in basic knowledge of clinical conditions, provided health coaching and connected patients to specific low and no-cost resources (e.g., food, transportation, housing-related) contributing to gaps in care. Using the framework of motivational interviewing and psychosocial support, CHWs sought to strengthen patient connections to primary care while addressing unmet needs.
To test the effect of CHW care delivery on 30-day readmission in a population insured by a Mass General Brigham accountable care organization, 278 participants were randomized to receive usual care along with the 30-day CHW intervention and 273 participants were randomized to usual care only. Members of the C-CAT study team enrolled patients on six internal medicine units from 2017 to 2019. CHWs met participants in-hospital prior to discharge.
Of the 550 participants analyzed, the mean age was 70.1, 48.4 percent were women, and 70.5 percent were Medicare insured. All trial participants had a mean of three hospitalizations in the 12 months prior. Overall, 24.5 percent of control and 21.7 percent of intervention participants were discharged to rehabilitation with a mean length of stay of 3.9 days.
Just 12.6 percent of intervention group participants were readmitted in the 30 days following hospital discharge, as opposed to 24.5 percent of control participants. However, Carter and her colleagues noted a statistically significant reduction in readmissions among patients discharged to rehabilitation but not in those discharged directly home: Intervention vs. control participants discharged to rehabilitation demonstrated a 32.3 percent reduction in readmissions (5.0 percent vs 37.3 percent) compared to a 5.7 percent reduction seen in those discharged home (14.7 percent vs 20.4 percent) . In addition, fewer intervention than control patients had missed appointments (22.0 percent vs. 33.7 percent) and ED visits (11.2 percent vs. 16.8 percent).
While the intervention effect was seen in patients discharged to short-stay rehabilitation prior to returning home, the researchers note that prior studies have shown that patients with complex co-morbidities discharged to rehabilitation facilities have markedly elevated rates of readmission, ranging from 28 percent to 75 percent. CHWs might have positively influenced these numbers by addressing unmet medical and social issues that occurred during the transition from rehabilitation to home, and improving communication between patients, rehabilitation staff, and the primary care providers after discharge.
Carter notes: “Surprisingly, there was a strong and significant reduction in 30-day readmissions for patients discharged to rehabilitation. This is a population with limited demonstrated interventions shown to improve outcomes. Additional research is needed to examine why this effect was seen as well as which patients benefited most from certain CHW intervention activities.”
Carter is an instructor in medicine at Harvard Medical School (HMS). Senior author Anne Thorndike is an investigator in the Division of General Internal Medicine at MGH and associate professor of medicine at HMS. Additional co-authors are CHW staff members Susan Hassan and Anne Walton; Karen Donelan of the MGH Department of Medicine and the Mongan Institute, as well as Stuart H. Altman Chair at the Heller School at Brandeis University; and Liyang Yu, bioinformatics specialist at MGH.
The study was supported by a Partners HealthCare Center for Population Health Delivery System Innovation Implementation Grant and the Healthcare Transformation Lab at MGH.