Feasibility and evaluation of a pilot community health worker intervention to reduce hospital readmissions

Int J Qual Health Care. 2014 Aug;26(4):358-65. doi: 10.1093/intqhc/mzu046. Epub 2014 Apr 16.


Objective: To pilot-test the feasibility and preliminary effect of a community health worker (CHW) intervention to reduce hospital readmissions.

Design: Patient-level randomized quality improvement intervention.

Setting: An academic medical center serving a predominantly low-income population in the Boston, Massachusetts area and 10 affiliated primary care practices.

Participants: Medical service patients with an in-network primary care physician who were discharged to home (n = 423) and had one of five risk factors for readmission within 30 days.

Intervention: Inpatient introductory visit and weekly post-discharge telephonic support for 4 weeks to assist patient in coordinating medical visits, obtaining and using medications, and in self-management.

Main outcome measures: Number of completed CHW contacts; CHW-reported barriers and facilitators to assisting patients; primary care, emergency department and inpatient care use.

Results: Roughly 70% of patients received at least one post-discharge CHW call; only 38% of patients received at least four calls as intended. Hospital readmission rates were lower among CHW patients (15.4%) compared with usual care (17.9%); the difference was not statistically significant.

Conclusion: Under performance-based payment systems, identifying cost-effective solutions for reducing hospital readmissions will be crucial to the economic survival of all hospitals, especially safety-net systems. This pilot study suggests that with appropriate supportive infrastructure, hospital-based CHWs may represent a feasible strategy for improving transitional care among vulnerable populations. An ongoing, randomized, controlled trial of a CHW intervention, developed according to the lessons of this pilot, will provide further insight into the utility of this approach to reducing readmissions.

Keywords: community health worker; inpatient readmissions; quality improvement; safety net.

Publication types

  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Community Health Workers / organization & administration*
  • Continuity of Patient Care / organization & administration*
  • Female
  • Health Services / statistics & numerical data
  • Humans
  • Male
  • Middle Aged
  • Patient Readmission / statistics & numerical data*
  • Patient Satisfaction
  • Physicians, Primary Care*
  • Pilot Projects
  • Poverty*
  • Risk Factors
  • Self Care
  • Telephone