A Patient Navigator Intervention to Reduce Hospital

Readmissions among High-Risk Safety-Net Patients:

A Randomized Controlled Trial
1,2 2,3 4
Richard B. Balaban, MD , Alison A. Galbraith, MD, MPH , Marguerite E. Burns, PhD ,
2,3 2,3
Catherine E. Vialle-Valentin, MD , Marc R. Larochelle, MD , and Dennis Ross-Degnan,
2,3
ScD
1 2
Cambridge Health Alliance, Harvard Medical School, Somerville Hospital Primary Care, Somerville, MA, USA; Harvard Medical School,
3 4
Somerville, MA, USA; Harvard Pilgrim Health Care Institute, Boston, MA, USA; University of Wisconsin, Madison, WI, USA.
(doi:10.1007/s11606-015-3185-x) contains supplementary material,
BACKGROUND: Evidence-based interventions to which is available to authorized users.
reduce hospital readmissions may not generalize to Received June 12, 2014
resource- constrained safety-net hospitals. Revised October 27, 2014
OBJECTIVE: To determine if an intervention by Accepted December 31, 2014
patient navigators (PNs), hospital-based Community Published online January 24, 2015
Health Workers, reduces readmissions among high
risk, low so- cioeconomic status patients.
DESIGN: Randomized controlled
trial.
PARTICIPANTS: General 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 ob- structive pulmonary disease. The
analytic sample includ- ed 585 intervention patients
and 925 controls. INTERVENTIONS: PNs 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 dis- charge preparation,
medication management, scheduling of follow-up
appointments, communication with primary care, and
symptom management.
MAIN MEASURES: The primary outcome was in-
network
30-day hospital readmissions. Secondary outcomes in-
cluded rates of outpatient follow-up. We evaluated
out- comes for the entire cohort and stratified by
patient age
>60 years (425 intervention/584 controls) and ≤60
years
(160 intervention/341
controls).
KEY RESULTS: Overall, 30-day readmission rates did
not differ between intervention and control patients.
How- ever, the two age groups demonstrated marked
differ- ences. Intervention patients >60 years showed a
statisti- cally 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. CONCLUSIONS: A patient navigator
intervention among high risk, safety-net patients
decreased readmission

NIH Trial Registration ClinicalTrials.gov identifier:

NCT01619098
Electronic supplementary material The online version of this
article

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.
KEY WORDS: care transitions; continuity of care; health care
delivery;
patient safety; underserved
populations. J Gen Intern Med
30(7):907–15
DOI: 10.1007/s11606-015-3185-
x
© Society of General Internal Medicine
2015
INTRODUCTION
Hospital readmission rates have been publicly reported
since
2009 by the Centers for Medicare and Medicaid Services
(CMS). In 2012, CMS instituted a payment penalty for
hos- pitals with higher than expected readmission rates,
focusing national attention on improving care transitions
1 costly community health workers (CHWs) , have
and reducing hospital readmissions. This policy poses
challenges for safety-net hospitals serving predominantly
patients of low socioeconomic status (SES) who contend
with social and financial hardships in addition to
2
established causes of read- mission. They are more likely
3
to be non-English speakers, have lower h ealth
4–6
literacy, w hich can i mpair s elf- management;
higher rates of mental health and substance abuse
7 6
disorders; greater exposure to social stressors; and are
8–10
more likely to experience hospital readmission.
11–16
Several care transitions programs have demonstrated
success in decreasing hospital readmissions. These
programs have primarily targeted elderly Medicare
populations or pa- tients with high risk diagnoses, such as
heart failure. However, key groups of challenging patients,
some of whom are dispro- portionately served at safety-net
hospitals, were excluded or underrepresented in these
17,18
studies, including non-elderly patients, non-English
speakers, patients with dementia, those who leave against
medical advice (AMA), and the homeless. Furthermore,
these programs used relatively expensive li- censed
personnel, such as nurse practitioners, pharmacists, or social
workers. Safety-net hospitals typically have limited
resources for new initiatives and professional staff. Less
19 20
increased med- ical follow-up with primary care and
21–23
specialists, im- proved adherence to medical
24, 25
regimens, and provided meaningful social
22
support. These competencies may
907
140 Balaban et al.: Patient Navigator Intervention to Reduce JGIM
140 Readmissions
JGIM Balaban et al.: Patient Navigator Intervention to Reduce 141
Readmissions 141
enhance post-discharge hospitals, three diagnosis of dementia. panel of 30–35 patients
transitional care and Emergency Departments The Institutional per full-time PN. A
reduce rehospitalizations. (EDs), and ten Review Boards of the computer algo- rithm
We implemented an community health centers. CHA and Harvard randomly assigned the
intervention led by CHA serves 100,000 Pilgrim Health Care PN-selected number of
hospital-based CHWs, or patients, one-third of approved the study as eligible patients to the
patient navigators (PNs), whom have a language- low risk and waived the intervention group and
designed to reduce of-care other than requirement for informed remaining eligibles to the
readmissions among high English. Patients were consent, as patient nav- controls. After
risk patients in a safety- recruited between October igators had been similarly randomization, patients
net medical system. We 2011 and April 2013. utilized for several years were excluded if they
assess the effects of this Enrollment was initially at in various settings within died in-house or
intervention in two Cambridge Hospital; in CHA. transferred to an ineligible
distinct patient September 2012, the service (e.g., psychiatry or
populations—those over protocol was modified R surgery), an outside acute
and under age to include Whidden a care hospital, a skilled
60—groups whose Hospital, expanding the n nursing facility (SNF),
distinctive distribution of pool of eligible patients. d long term care, or jail.
medical and psychiatric We randomized patients o
26–28
comorbidities and to the intervention or m C
different networks of control group during their i o
29,30
social support shape first admission in the z n
their post-discharge needs study period that met the a t
and potentially their criteria for study entry, t r
response to the PN namely; having a primary i o
intervention. care provider (PCP) o l
within CHA; observation n
or inpatient admission on G
CHA’s general medicine Eligible patients were
M identified daily using the r
service; community o
E hospital elec- tronic
T dweller; and discharged to u
a community setting (i.e., medical record (EMR).
H PNs determined how p
O home, assisted living,
shelter, or street). many intervention Control patients
D
Additionally, eligible patients to enroll each received usual inpatient
S
patients had at least one day, aiming to maintain a and outpatient care.
Stu Patient treatment and
of five risk factors
dy discharge plans are
associated with elevated
Sett discussed daily at
readmission rates
ing documented in previous multidisciplinary
an 31–35 rounds. Each patient is
studies and in CHA
d assigned a case
histor- ical data: (1) age
Par manager who organizes
>60 years; (2) admission
tici post-discharge care
to CHA’s general
pa including visiting nurses,
medicine, surgery, or
nts psychiatry service within home care, durable med-
We conducted a the past ical supplies, or referral
randomized, controlled 6 months; (3) length of to substance abuse
trial among hospital- ized stay (LOS) ≥3 days; and programs or homeless
patients within Cambridge (4) admission diagnosis of shelters. At discharge, a
Health Alliance (CHA), heart failure or (5) chronic floor nurse reviews
an academic public obstructive pulmonary written discharge
safety-net system with an disease. Notably, our instructions with the
ethnically diverse and eligible population patient, including an
traditionally underserved included non-English updated medication list,
patient population. CHA speakers, patients who scheduled appointments,
is an integrated health care left AMA, were and patient education.
provider comprising two homeless, or had a After discharge, a nurse
 142 Balaban et al.: Patient Navigator Intervention to Reduce JGIM
142 Readmissions
from their primary care scripts to promote
site attempts to standardization, lasted for
telephone patients 30 days post-discharge,
within and included hospital
2 business days to visits and weekly post-
assess patients’ discharge outreach calls.
medication adher- ence, The intervention protocol
confirm scheduled was fulfilled by one
appointments, hospital visit and three
availability of complet- ed calls. The
transportation, and PNs coached patients to
identify issues requiring independently direct their
immediate attention. medical care, but actively
coordinated care for
I patients less capable of
n self-management. PNs
t wrote a brief EMR note
e summarizing each
r completed call, which
v was sent to the patient’s
e primary care nursing staff.
n If unable to reach patients
t after three attempts, a
i voicemail was left with
o PN contact details and
n pending appointment
information. The PNs
G coded the content of all
r outreach using a
o customized database.
u The PNs had a broad
p range of tasks and
The PN intervention, responsibilities.
piloted in 2010,
36
is Prior to discharge, the
designed to assist patients PNs conducted
with the logistics of introductory visit(s) with
navigating a complicated the patient and caregivers
system to optimize post- to establish rapport,
discharge care (Fig. 1). describe the PN program,
PNs received exten- sive and assess post-discharge
training and ongoing needs; assisted patient in
supervision (see communicating with
Supplemental Appendix inpatient providers to
A, available online). Two address post-discharge
of the three PNs were concerns; verified patient’s
native Portuguese- post-discharge con- tact
speakers; telephone information and confirmed
interpreters were used for convenient times for
other languages. Patients outreach;
were assigned to PNs
based on panel size and
language concordance
between the PN and
patient; otherwise
assignments alternated
between PNs.
The intervention used
JGIM Balaban et al.: Patient Navigator Intervention to Reduce 143
Readmissions 143

Figure 1 Patient navigator roles and responsibilities: the interaction of the hospital-based patient navigators with patients, family, and
other care team members during the hospital stay, transition to home, and return to primary care.
144 Balaban et al.: Patient Navigator Intervention to Reduce JGIM
144 Readmissions
highlighted the readmission (observa- tion readmissions were not We first examined
importance of obtaining or full admission) to any excluded. Secondary differences in
new medications, having service (including outcomes were attending demographic and clinical
timely outpatient follow- medicine, surgery, or a primary care descriptors between PN
up, and reporting psychiatry) within 30 days appointment within 7 and control patients, and
concerning symptoms; post-discharge. Planned days and any outpatient between patients over and
and alerted PCP offices of or ED visit within 30 under age 60, using chi-
a patient’s discharge. days of discharge. square or t-tests, as
After discharge, appropriate. We next
through weekly telephone S compared measures of
contacts, the PNs t intervention fi- delity
confirmed appointments a between patients over and
and rescheduled as t under age 60 using chi-
needed; ad- dressed i square tests. We used
barriers to obtaining or s logistic regression to
taking medications; t examine the association
identified concerning i between PN/control study
symptoms and facilitated c assignment and our
communication with PCP a outcomes of inte rest,
offices; assisted with l adjusting f or ge nde r,
transportation; reassessed language pre fere nce ,
patients’ home care needs A
and made connections to n
community ser- vices; a
assisted with health
l
insurance issues;
y
supported patient self-
s
management; and helped
i
patients navigate the
s
health care system.
We aimed to enroll 2,600
Study patients to provide 80 %
Data and power to detect absolute
Outcome changes of 0.033 to 0.043
Measure in the proportion of
s 30-day readmissions for
baseline readmission
Data on patient
rates ranging from 0.15
demographics, health
to 0.25 for PN patients
insurance, comorbidi-
compared to controls.
ties, hospital
The trial ended when the
readmissions, ED visits,
PN’s completed their
and primary care ap-
prespecified period of
pointments were
effort, having enrolled
abstracted from the EMR.
1,510 patients. In setting
Charlson comor- bidity
a target of
scores were calculated
2,600 patients, we had
from diagnoses associated
not fully anticipated the
with the initial, qualifying
large number of repeat
hospitalization. Measures
admissions, which
of intervention fidelity
limited the number of
included the number of
eligible index discharges.
PN hospital visits,
Additionally, the
attempted and completed
intervention was more
calls. The prespecified
time-consuming than
primary outcome mea-
expected, limiting
sure was in-network all-
enrollment in the PN
cause hospital
arm.
142 Balaban et al.: Patient Navigator Intervention to Reduce JGIM
142 Readmissions
JGIM Balaban et al.: Patient Navigator Intervention to Reduce 143
Readmissions 143
race/ethnicity, insurance, a population, intervention assisted patients primarily
Charlson score, r patients had higher with med- ical and
psychiatric and sub- a Charlson comor- bidity medication issues,
stance abuse diagnoses, c scores (1.63 vs. 1.45; p = appointments, and
our identified readmission t 0.005), while controls transportation. Older
risk factors, and assigned e had more behavioral patients received more
hospital. health issues (44.7 % vs. assistance with medical
r
We performed an 37.6 %; p = 0.025) issues, medications, and
i
intention-to-treat (results not shown). transportation.
s
analysis, modeling Among those under 60,
t
outcomes in the overall intervention patients had
i
study cohort, and in a higher percentage of
c
patients over and under admissions in the past 6
s months (65.6 % vs. 49.9
age 60. Our original
analytic plan called for Of 12,488 first %; p < 0.001) (results not
subgroup analyses admissions to the general shown).
according to Medicare medicine service during
enrollment status; the study period, 1,937 F
however, we revised met the eligibility criteria i
this plan early in the of which 747 were d
trial. The trial inclusion randomized to the PN e
criteria allowed patients intervention and 1,190 to l
over age 60 to qualify controls. After exclusions, i
based solely on age the analytic sample t
without other risk factors, included 585 intervention y
while patients under 60 patients and 925 controls.
had to have at least Ten patients opting out of o
one risk factor other the intervention were f
than age. Consequently, analyzed in the PN group
the two groups exhibited and were similar to PN
I
very different risk enrollees in all
m
profiles, affecting characteristics except for a
p
potential response to the shorter LOS (1.8 days)
l
PN intervention. (Fig. 2).
e
The study population,
m
consistent with its low
e
SES, was highly diverse
R in race and language,
n
E almost exclusively pub- t
S licly insured, with a high a
U burden of psychiatric t
L illness and substance i
T abuse (Table 1). Older o
S n
patients were more
P medically complex with The PNs met with
a higher Charlson virtually all patients while
r comorbidity scores, while hospitalized and were
t younger patients had resolute in attempting to
i significantly more mental contact patients after
c illness, sub- stance abuse, discharge. The PNs were
i and higher rates of more successful
p previous hospitalizations contacting older
a and LOS >3 days. compared to younger
n Randomization elicited patients post-discharge
t comparable intervention and thus more likely to
and con- trol groups, with deliver a complete
C exceptions noted in Table intervention (Table 2).
h 1. In the over 60 As planned, the PNs
 144 Balaban et al.: Patient Navigator Intervention to Reduce JGIM
144 Readmissions
O Rates of ED visits within patients with medication
u 30 days did not differ management, symptom
t between groups, control, outpatient follow-
c regardless of age. up, and self-care. The PNs
o were empathic and
m caring, forming
e D relationships that could
s I motivate patients to
S engage more fully in their
Results from unadjusted C 38
health care.
analyses were consistent U Intervention patients
with the adjusted S trended toward higher
analyses, and in most S rates of 7-day primary
cases, had similar patterns I care follow-up and had
of statistical significance O significantly more
(Table 3). We observed no N
outpatient appointments
difference in This randomized within 30 days, visits that
30-day readmission rates controlled trial evaluated could play an impor- tant
between intervention and a PN intervention using role in preventing
control patients for the low-cost CHWs to readmission.
39,40
entire study population improve care transitions The reduction in
(full model results in for general medicine readmissions among
Supplemental Appendix inpatients discharged to those over 60 is similar
B, available online). home. While previous to other effective post-
11,15
However, the two age stud- ies evaluated general discharge programs.
subgroups had markedly medical populations in However, ours is the first
different, statistically safety-net hospi- tals,
14,37 study to successfully
signif- icant responses to ours is the first to target employ CHWs in
the PN intervention. The patients at high risk for reducing readmissions in
older group expe- rienced readmission in this setting. an older population.
an adjusted absolute 4.1 % The PN intervention did While not medically
decrease [95 % CI: −8.0 not reduce hospital licensed, the PNs were
%, readmissions among the trained to
-0.2 %] in readmission; full cohort of patients;
conversely, the younger how- ever, we found
PN group experienced an dramatically different
adjusted absolute 11.8 % responses related to
increase [95 % CI: patient age.
4.4 %, 19.0 %] in Among patients older
readmission. Of note, than 60, the PN
psychiatric intervention signifi- cantly
readmissions (12.2 % of decreased 30-day
younger and 2.0 % of readmissions compared to
older patients) occurred controls. The PNs
evenly between implemented the key
intervention and control components of a well-
patients; removing these functioning care
did not change results. transitions program. They
For older intervention made hospital visits to 97
patients, rates of primary % of older patients,
care follow- up at 7 days allowing an
trended higher and individualized
outpatient visits within 30 understanding of patients’
days were significantly transitional needs. More
higher compared to than 60 % of older
controls. No significant patients received three or
differences were seen in more outreach calls,
the younger population. allowing PNs to assist
JGIM Balaban et al.: Patient Navigator Intervention to Reduce 145
Readmissions 145

Figure 2 Patient participation flow.

146 Balaban et al.: Patient Navigator Intervention to Reduce JGIM
146 Readmissions
recognize when medical substance abuse unit
assistance was necessary assigned to a peer
and could readily engage mentorship
41
primary care nursing; intervention; medically
they also provided complex Veterans
logistical assistance and Affairs pa- tients who
motivational support. received intensive
42
Achieving comparable primary care support;
readmission reductions younger general
at lower cost may medicine patients
heighten interest in this assigned to nurse case
strategy, particularly at managers coordinating
43
financially constrained outpatient care; and
safety-net institutions. pa- tients with heart
Among patients failure assigned to a
under age 60, PNs comprehensive treatment
44
visited nearly program. Explanations
95 % in-hospital and 83 for these paradoxical
% received at least one findings included:
post- discharge call. increased receptiveness
However, it was more to inpatient treatment for
challenging to engage long-standing
41
younger patients over psychiatric disorders;
the 30-day period, as im- proved provider-
25 % fewer received patient communication
the complete facilitating de- tection
intervention com- pared and treatment of
with older patients. undiagnosed medical
42
There were only small prob- lems;
non- significant patients b etter e
increases in outpatient nable d to self-
follow-up among identify concerning
younger PN patients, symptoms and seek
42
which may reflect medical care; person-
weaker ties to primary nel added to the care
care or other access team increased
barriers. Yet the complexity, impairing
patients’ ability to self-
startling 45
11.8 % adjusted care; and patients
increase in the using the hospital as
respite from housing or
readmission rate among 7
PN patients compared to social problems.
controls was unforeseen, Furthermore, other
studies have
espe- cially in the
demonstrated that
context of readmission
increased outpatient
reductions among older
contact (e.g., PN
patients. outreach) may be
These findings are not associated with more
unprecedented. Several readmissions,
care transition programs particularly among
have reported increased younger low SES
readmissions of up to patients,
46, 47
suggesting
96 %: high-risk that such patients may
inpatients on a need more finely
psychiatric- targeted, and possi- bly
more intensive,
outpatient care.
JGIM Balaban et al.: Patient Navigator Intervention to Reduce 147
Readmissions 147

Table 1 Baseline Characteristics of the Study Sample by Intervention Group and Age Group

PN Ctrl 60 years old+ ≤60 years old

(N=585) (N=925) (N=1009) (N=501)

p-value p-value
Age at discharge, mean (SD) 66.4 (15.5) 63.7 (16.7) 0.001 74 (9.3) 46.1 (10.3) <0.001
Female, n (%) 323 (55.2) 548 (59.2) 0.123 611 (60.6) 260 (51.9) 0.001
Language, n (%) 0.064 <0.001
English 363 (62.1) 583 (63.0) 563 (55.8) 383
(76.4) Portuguese 97 (16.6) 113 (12.2) 163 (16.2) 47
Spanish 43 (7.4) 88 (9.5) 86 (8.5) 45 (9.0)
Other 82 (14.0) 141 (15.2) 197 (19.5) 26 (5.2)
Race, n (%) 0.800 <0.001
White 337 (57.6) 532 (57.5) 585 (58.0) 284 (56.7)
Black 94 (16.1) 144 (15.6) 177 (17.5) 61 (12.2)
Hispanic 86 (14.7) 151 (16.3) 123 (12.2) 114 (22.8)
Other 68 (11.6) 98 (10.6) 124 (12.3) 42 (8.4)
Health insurance type, n (%) 0.623 <0.001
Medicare 174 (29.7) 245 (26.5) 407 (40.3) 12 (2.4)
Medicaid 165 (28.2) 276 (29.8) 199 (19.7) 242 (48.3)
Duals Medicare and Medicaid 135 (23.1) 208 (22.5) 237 (23.5) 106 (21.2)
Health Safety Net* 70 (12.0) 123 (13.3) 118 (11.7) 75 (15.0)
Commercial/other 41 (7.0) 73 (7.9) 48 (4.8) 66 (13.2)
Weighted Charlson score, mean (SD) 1.3 (1.6) 1.1 (1.5) 0.004 1.3 (1.5) 0.9 (1.5) <0.001
Chronic behavioral health issues
Substance abuse or psychiatric diagnosis, n (%) 272 (46.5) 494 (53.4) 0.009 421 (41.7) 345 (68.9) <0.001
Psychiatric diagnosis†, n (%) 222 (37.9) 397 (42.9) 0.056 348 (34.5) 271 (54.1) <0.001
Substance abuse‡, n (%) 126 (21.5) 272 (29.4) <0.001 159 (15.8) 239 (47.7) <0.001
Dementia 65(11.1) 109(11.8) 0.690 107(10.6) 67(13.4) 0.113
Qualifying risks of readmission
60 years old+, n (%) 425 (72.6) 584 (63.1) <0.001
Index admission, LOS ≥3 days, n (%) 261 (44.6) 467 (50.5) 0.026 395 (39.1) 333 (66.5) <0.001
Admission at CHA in past 6 months, n (%) 167 (28.5) 257 (27.8) 0.748 149 (14.8) 275 (54.9) <0.001
COPD§, n (%) 50 (8.5) 63 (6.8) 0.212 71 (7.0) 42 (8.4) 0.349
Heart failure§, n (%) 40 (6.8) 38 (4.1) 0.020 65 (6.4) 13 (2.6) 0.001
Outpatient visit(s) in previous month, n (%) 360 (61.5) 570 (61.6) 0.974 611 (60.6) 319 (63.7) 0.241
Length of stay, mean (SD) 3 (2.4) 3.5 (3.8) 0.003 2.8 (3.0) 4.3 (3.8) <0.001
Discharge against medical advice, n(%) 12(2.1) 16(1.7) 0.652 9(0.9) 19(3.8) <0.001
*
†
Health Safety Net is a Massachusetts state program for uninsured patients
Based on ICD-9 discharge codes: 290–302.9 and 306–319
‡
Based on ICD-9 discharge codes: 303–305.93
§
Based on primary Emergency Department admission diagnosis
148 Balaban et al.: Patient Navigator Intervention to Reduce JGIM
148 Readmissions
Additionally, younger, network readmissions
low SES patients have would occur equally
exhibited high utilization between interven- tion
48,49
of hospital-based care, and control patients;
possibly reflecting an however, even a small
underlying belief that imbalance in unobserved
hospital-based care is out-of-network
easier to access and of rehospitalizations might
50
higher quality. Because render our estimated
PNs were hospital-based, reductions in readmissions
their supportive work among older patients
may have unintentionally nonsignificant. On the
encouraged younger other hand, a positive
patients to return to the experience with a PN
hospital for medical care. might have led some
Finally, the higher rate of intervention patients to
previous admissions selectively choose a CHA
among younger PN- hospital for readmission;
assigned patients might in this case, our
indicate that this group readmission reductions
was predisposed to higher with the older population
readmission rates. Future may actually be
qualitative studies may underestimated.
elucidate our paradoxical Second, because
findings, as it is chal- discharge coordinators
lenging to identify the often knew which patients
most likely explanation were assigned post-
from our study data. discharge PN support,
The markedly different they may have had
responses to the PN increased comfort
intervention highlight the discharging PN patients
need to evaluate care
home (vs. SNF) compared
transition strategies in
with controls who lacked
different settings and with
extra support. In- deed,
different populations.
among older patients, a
Even well- validated
significantly higher
programs, such as the
percentage of controls vs.
Care Transitions
PN-patients (19.5 % vs.
Interven- tion®, have
15.1 %, data not shown)
performed differently or
required modifications to was discharged to SNFs
51 and consequently
succeed in new venues.
excluded from analysis.
Our study has several
Thus, the older PN group
limitations. First, without
may have had sicker
access to claims data, we
patients discharged to
assess utilization only
home, making
within CHA’s network;
we do not observe out-of- readmission more likely.
network readmissions, If correct, decreased
estimated to comprise 20 readmissions among older
52 patients may again be
% of all readmissions.
underestimated.
We expected that non-
Third, we evaluated
30-day post-discharge
utilization, the most
frequently used time
frame for assessing
transitional
JGIM Balaban et al.: Patient Navigator Intervention to Reduce 149
Readmissions 149

Table 2 Fidelity of Patient Navigator Intervention Implementation and Description of Issues Addressed, Stratified by Age Group

60 years old+ ≤60 years old

(N=425) (N=160)
n (%) n (%) p-value
Fidelity of implementation
Hospital visits during index hospitalization 0.051
PN did not visit patient 13 (3.1) 9 (5.6)
PN visited patient once 194 (45.6) 57 (35.6)
PN visited patient more than once 218 (51.3) 94 (58.8)
Attempted outreach calls w/in 30 days of index discharge* 0.004
PN did not attempt to call patient 37 (8.7) 4 (2.5)
PN attempted to call patient 1–2 times 30 (7.1) 21 (13.1)
PN attempted to call patient 3+ times 358 (84.2) 135 (84.4)
Successful outreach calls w/in 30 days of index discharge* 0.007
PN did not speak to patient/caregiver 46 (10.8) 27 (16.9)
PN successfully contacted patient/caregiver 1–2 times 120 (28.2) 58 (36.3)
PN successfully contacted patient/caregiver 3+ times 259 (60.9) 75 (46.9)
Full implementation† 257 (60.5) 74 (46.3) 0.002
Issues addressed
Medical needs or problems
PN reviewed medical issues in discharge plan 285 (67.1) 85 (53.1) 0.002
PN identified medical issues 211 (49.6) 66 (41.3) 0.070
PN identified medication issues 201 (47.3) 58 (36.3) 0.017
PN identified a medical emergency 6 (1.4) 4 (2.5) 0.365
Follow-up appointments
PN contacted patient about an appointment reminder 337 (79.3) 126 (78.8) 0.885
PN helped patient with scheduling an appointment 159 (37.4) 64 (40) 0.566
Other
Arranging transportation 152 (35.8) 44 (27.5) 0.059
Home services 38 (8.9) 6 (3.8) 0.034
Medical insurance 13 (3.1) 6 (3.8) 0.674
*
Or before readmission if readmitted within 30 days
†
Defined as patient received 1+ hospital visit by PN and 3+ successful outreach calls from PN
150 Balaban et al.: Patient Navigator Intervention to Reduce JGIM
150 Readmissions
care. However, 30 days is a short period to effect change, Fourth, our analysis considered one qualifying admis-
especially for patients with complex behavioral health sion per patient. This widely used approach minimizes
issues. Future studies should evaluate longer term effects of the impact of high utilizers, but may better represent an
CHW- based care transition interventions. intervention’s effectiveness across different populations.

Table 3 Adjusted and Unadjusted Trial Results for All Patients and Stratified by Age Group

Difference in rate of outcome

(PN-Ctrl)
Unadjusted Adjusted*
All (N=1,510) PN (n=585) Ctrl (n=925)
Readmission w/in 30 days of index discharge (%) 14.2 13.1 1.1 [−2.5, 4.7] 0.4 [−3.1, 3.8]
PCP visit w/in 7 days of index discharge (%) 27.9 22.6 5.3 [0.8, 9.8] 5.1 [0.6, 9.6]
Outpatient visit w/in 30 days of index discharge 83.3 78.5 4.8 [0.7, 8.8] 4.9 [0.9, 8.9]
ED visit w/in 30 days of index discharge (%)† 13.5 11.6 1.9 [−1.5, 5.4] 2.6 [−0.9, 6.0]
60years old+ (N=1009) PN (n=425) Ctrl (n=584)
Readmission w/in 30 days of index discharge (%) 10.1 13.5 −3.4 [−7.4, 0.6] −4.1 [−8.0, −0.2]
PCP visit w/in 7 days of index discharge (%) 29.9 25.2 4.7 [−0.9, 10.0] 4.9 [−0.7, 10.0]
Outpatient visit w/in 30 days of index discharge 85.2 79.1 6.1 [1.3, 11.0] 6.7 [2.0, 11.0]
ED visit w/in 30 days of index discharge (%)† 9.4 8.1 1.4 [−2.2, 4.9] 1.1 [−2.4, 4.7]
≤60 years old (N=501) PN (n=160) Ctrl (n=341)
Readmission w/in 30 days of index discharge (%) 25.0 12.3 12.7 [5.1, 20.0] 11.8 [4.4, 19.0]
PCP visit w/in 7 days of index discharge (%) 22.5 18.2 4.3 [−3.3, 12.0] 4.6 [−3.1, 12.0]
Outpatient visit w/in 30 days of index discharge 78.1 77.4 0.7 [−7.1, 8.5] 3.8 [−3.7, 11.0]
ED visit w/in 30 days of index discharge (%)† 24.4 17.6 6.8 [−1.0, 15.0] 6.2 [−1.6, 14.0]
Bold indicates p<0.05
*
Adjusted for gender, language, race/ethnicity (black, Hispanic, other compared to white), health insurance (Medicaid or dual status, Health Safety
Net, commercial compared to Medicare), readmission risk factors, comorbidities, chronic behavioral health issues, and index hospital (Whidden
compared to Cambridge Hospital)
†
ED visits with discharge to
home
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