Navigating high-risk in-patient clients using a lay-health worker model in Eastern Kentucky

The primary objective of this study is to decrease 30-day hospital readmission rates. A validated algorithm (the LACE index) will identify clients at high risk for hospital readmission at the time of hospital presentation and be assigned to a lay health worker (LHW) who will further assess clients for specific needs and help link them to their post-admission appointments and social and health services in their community. Secondary objectives and measures include quality of life, discharge planning adherence/compliance, and patient satisfaction Significance: Clients may benefit from additional post-discharge care and navigation, decreasing unplanned hospital readmission rates. Other benefits include the reduction of healthcare expenditures and (as of recently) hospital loss of Medicaid reimbursement and other penalties. Relevance: Hospital readmission rates are generally higher among Medicaid clients than any other payer source clients, especially in disadvantaged areas such as Eastern Kentucky. Our proposed study will benefit Medicaid clients admitted to St. Claire Hospital. Basic Study Design and Methodology: Clients presenting to the hospital/ED (St. Claire Hospital, Morehead, KY) will be assessed for their risk of 30-day hospital readmission based on the LACE index. Clients determined to be high risk will be visited by a trained lay health worker (LHW). During this visit, the LHW will complete a detailed assessment of the clients’ social factors and health determinants. The LHW, social workers and discharge planning nurses will develop a client-centered priority care plan. The LHW will conduct a follow-up call 24-48 hours after discharge to review any issues during the interim, and ensure plans are in place for appropriate follow-up visits. LHWs will make pre-visit reminder calls for any post-hospital-specific appointments, and will follow-up at 1 week after the last scheduled post-hospital visit to review clients’ status and outcome measures. To determine the effectiveness of this readmission assessment and LHW model, outcome measures for the 6-months prior to study implementation, and outcome rates 6-months after the study intervention will be compared. Feasibility and Potential Pitfalls: St. Claire Hospital and the University of Kentucky have a long standing working relationship in education and research. Dr. Cardarelli currently has a collaborative project related to lung cancer screening and pending applications related to population-based colorectal cancer that involves St. Claire Hospital. Ms. Horsley is supported in part by UK to create and sustain such collaborative projects. Pitfalls include being overwhelmed with high risk clients but this demonstration project would provide the evidence to sustain in-patient lay-health workers positions.