부산대학교 도서관

Keywords: care transitions; community health workers; healthcare utilization Abstract Background/Objectives Healthcare systems' adoption and sustenance of successful transitional care models (TCMs) have been limited by cost-prohibitive resource needs. Cost-effective TCMs that improve patient outcomes are needed to promote adoption by healthcare systems and sustainability. This study evaluated the effectiveness of a TCM utilizing community health workers (CHWs) in reducing inappropriate healthcare utilization and costs. Design A cohort study with a pre-post intervention evaluation of the intervention group. Setting A 953-bed academic urban safety-net hospital. Participants Eligible participants (N = 154) were hospitalized or had repeated emergency room (ER) visits, identified to be at high risk for readmission. Intervention Promotion of self-management skills acquisition and care coordination by CHWs achieved through predischarge interdisciplinary team meetings, regular home visits and phone contact, accompaniment to primary care physicians' (PCP) appointments, support with transportation, medications, and self-management education. Measurements Outcome measures were readmissions, ER visits, and PCP establishment. Results Mean age of participants was 67, 65% were male, 92% African American. There was a significant reduction in overall number of readmissions (Z =9.6, p Conclusion Use of CHWs during transitions of care may be a cost-effective approach to reducing healthcare utilization and costs and may promote adoption and sustainability within healthcare systems. Article Note: The data from this study were presented at the International Association of Gerontology and Geriatrics World Congress, San Francisco, California, USA, July 2017. See related editorial by WilliamJ.Hall in this issue. Funding information Kaiser Permanente; United Way of Greater Atlanta Byline: Ebony Johnson, Joyce Turner, Queenie Jordan, Victor Popoola, Jonathan Flacker