Readmissions may drop with adjustment

A technology assessment tool may help non-medical workers identify who is at risk for readmissions, according to a new study.

The research, published in Perspectives in Health Information Management in February, focused on Care at Hand, described as a “smart” STOP and WATCH tool used in risk assessments. The platform is designed for early detection of risk factors.

Data consistently suggest non-medical workers, such as community health assistants, should be considered for use in care transition interventions, with the assistance of mobile risk prediction technology, said Care at Hand CEO Andrey Ostrovsky, M.D.

The study began with Elder Services of Merrimack Valley using the technology for quality improvement. Its goal was to reduce rehospitalizations among its 2,000 clients. 

It found non-medical workers could be helpful in risk prediction, which improved with clinician oversight. Before the project started, the 30-day readmission rate for the three-month period preceding was 17.6%, which dropped to 14.5% in the last month of data collection. 

The findings reflect how non-medical workers can spend more time with patients, noted study co-author Lori O'Connor, RN, chief nursing officer at Care at Hand. “They develop a stronger relationship,” she told McKnight's

In one recent case, a patient went from the hospital to a skilled nursing facility several times, and had frequent urinary tract and kidney infections. The community health worker noticed two weeks after discharge that the patient wasn't herself.

“The trigger was the question, ‘Is the patient acting differently?' which triggered an alert to the nurse,” O'Connor shared. “After talking to the patient, the nurse called the primary care physician.  Someone came out and took a sample, and we found she had another UTI.” 

The case illustrated a way to keep a patient from bouncing back to the hospital, “saving tremendous costs, and providing better care.”