Cardarelli Roberto, Horsley Mary, Ray Lisa, Maggard Nancy, Schilling Jennifer, Weatherford Sarah, Feltner Fran, Gilliam Kayla
Department of Family and Community Medicine, University of Kentucky College of Medicine, Lexington 40504, USA.
St. Claire Regional Medical Center, Morehead 40351, USA.
Health Educ Res. 2018 Feb 1;33(1):73-80. doi: 10.1093/her/cyx064.
This exploratory study aimed to address the effectiveness of a lay-health worker (LHW) model in addressing social needs and readmissions of high-risk patients admitted in a rural community hospital. A quasi-experimental study design assessed implementation of a LHW model for assisting high-risk patients with their post-discharge social needs. Outcome measures included 30-day hospital readmissions rates during a 4-month baseline period compared with a 6-month post-implementation period. The LHW intervention involved assessment and development of a personalized social needs plan for enrolled patients (e.g. transportation and community resource identification), with post-discharge follow-up calls. There was a 47.7% relative reduction of 30-day hospital readmissions rates between baseline and intervention phases of the study. Simple regression analyses demonstrated a 56% decrease in odds (90% confidence interval 0.20-0.98) in being readmitted within 30-days among those in the intervention phase compared with those in the baseline phase. Once adjusting for education, transportation cost and anxiety symptoms, there was a 77% decrease in odds among those exposed to the LHW program. LHWs offer an effective hospital-based model to improve transitions in care from the hospital setting, especially those at high-risk with persistent social needs.
这项探索性研究旨在探讨非专业卫生工作者（LHW）模式在满足农村社区医院收治的高危患者的社会需求和再入院方面的有效性。一项准实验研究设计评估了LHW模式在协助高危患者满足出院后社会需求方面的实施情况。结果指标包括在4个月的基线期与实施后的6个月期间的30天医院再入院率。LHW干预包括为登记患者评估和制定个性化社会需求计划（如交通和社区资源识别），并在出院后进行随访电话。在研究的基线期和干预期之间，30天医院再入院率相对降低了47.7%。简单回归分析表明，与基线期相比，干预期内30天内再入院的几率降低了56%（90%置信区间0.20-0.98）。在调整了教育程度、交通成本和焦虑症状后，接受LHW项目的人群再入院几率降低了77%。LHW提供了一种有效的基于医院的模式，以改善从医院环境的护理过渡，特别是那些有持续社会需求的高危人群。
