The healthAlign team led a multi-year project that effectively helped reduce readmissions by half and drove down inpatient spending by 35 percent for high risk patients
From late 2014 to the end of 2019, the healthAlign team partnered with a hospital system in MD on a program deploying Community Health Workers (CHWs), frontline public health workers with a strong understanding of community resources, to help patients at high risk for hospital readmission due to medical, psychological, functional and socioeconomic complexity.
Data collected in 2017 and the first half of 2018 shows only 8 percent of program participants were readmitted to the hospital within 30 days of discharge compared with 18 percent of non-program participants. Only 23 percent of program participants returned to the hospital within 90 days post discharge compared with 34 percent of non-program participants. Over a two-year period, the reduction in readmissions represents more than $3 million in savings and a 3.8:1 return on investment.
The program also had an impact on per-patient hospital charges in the months before and after program enrollment. Participants continued to generate lower hospital charges after the 30-day program was complete. Per-patient charges for participants decreased by 35 percent after 30 days and by 9 percent after 90 days. At the same time, non-program participants saw pre- to post-discharge charges decrease by 4 percent after 30 days and actually increase by 12 percent at 90 days.
"The key to the success of this program is a strong focus on the social and behavioral barriers that keep many patients from adhering to their clinical plans. Through the use of CHWs, our team was able to help high-risk patients transition back to their homes without heightening their risk for readmission. The benefits of this approach come into even sharper focus when you consider that a full year of this type of community-based program is less expensive than an average 27-day stay in a skilled nursing facility and roughly half the cost of the average readmission."
Andy Friedell, Founder & CEO of healthAlign
The analysis followed 1,778 patients over a three-month period who were identified during their hospitalization as being at high risk for readmission. Of that group, 840 patients enrolled in the program and used CHW services while 938 did not enroll or did not respond to outreach following discharge from UMSJMC. Data provided by Maryland's Health Information Exchange was also analyzed to establish visit and hospital charge information across all Maryland hospitals. The analysis affirms a previously released report, which showed a 65 percent reduction in readmissions in the first 16 months following the program's launch in 2015. Patients enrolled in the program are assigned a CHW who is specially trained to address issues such as transportation, housing, employment and access to medical services that are often barriers to care following discharge.