• Richard B Balaban, Alison A Galbraith, Marguerite E Burns, Catherine E Vialle-Valentin, Marc R Larochelle, and Dennis Ross-Degnan.
• Cambridge Health Alliance, Harvard Medical School, Somerville Hospital Primary Care, 236 Highland Ave., Somerville, MA, 02143, USA, rbalaban@challiance.org.
• J Gen Intern Med. 2015 Jul 1; 30 (7): 907-15.

BackgroundEvidence-based interventions to reduce hospital readmissions may not generalize to resource-constrained safety-net hospitals.ObjectiveTo determine if an intervention by patient navigators (PNs), hospital-based Community Health Workers, reduces readmissions among high risk, low socioeconomic status patients.DesignRandomized controlled trial.ParticipantsGeneral medicine inpatients having at least one of the following readmission risk factors: (1) age ≥60 years, (2) any in-network inpatient admission within the past 6 months, (3) length of stay ≥3 days, (4) admission diagnosis of heart failure, or (5) chronic obstructive pulmonary disease. The analytic sample included 585 intervention patients and 925 controls.InterventionsPNs provided coaching and assistance in navigating the transition from hospital to home through hospital visits and weekly telephone outreach, supporting patients for 30 days post-discharge with discharge preparation, medication management, scheduling of follow-up appointments, communication with primary care, and symptom management.Main MeasuresThe primary outcome was in-network 30-day hospital readmissions. Secondary outcomes included rates of outpatient follow-up. We evaluated outcomes for the entire cohort and stratified by patient age >60 years (425 intervention/584 controls) and ≤60 years (160 intervention/341 controls).Key ResultsOverall, 30-day readmission rates did not differ between intervention and control patients. However, the two age groups demonstrated marked differences. Intervention patients >60 years showed a statistically significant adjusted absolute 4.1% decrease [95% CI: -8.0%, -0.2%] in readmission with an increase in 30-day outpatient follow-up. Intervention patients ≤60 years showed a statistically significant adjusted absolute 11.8% increase [95% CI: 4.4%, 19.0%] in readmission with no change in 30-day outpatient follow-up.ConclusionsA patient navigator intervention among high risk, safety-net patients decreased readmission among older patients while increasing readmissions among younger patients. Care transition strategies should be evaluated among diverse populations, and younger high risk patients may require novel strategies.

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