A Holistic Approach to Reducing Hospital Readmission Rates

When the Centers for Medicaid & Medicare Services (CMS) introduced the Hospital Readmissions Reduction Program in 2012, healthcare organizations across the United States faced a considerable challenge. How would we improve health outcomes for high-risk patients and, in turn, decrease the number of hospital readmissions?

We knew that social determinants are often the root cause of illness and are key to understanding and addressing health disparities. And it was clear that the industry needed to evolve from diagnosis-specific interventions that react to a medical problem to an all-inclusive, proactive approach that focuses on the comprehensive needs—both medical and social—of each patient. But the cost associated with multiplying the number of case workers and nurse navigators as required to tackle social barriers presented its own challenges.

At Lankenau Medical Center, part of Main Line Health in southeastern Pennsylvania, we serve patients who have abundant resources as well as those with limited access to care and wellness options. Our hospital is situated between two contrasting neighborhoods: Montgomery County, generally ranked as the third-healthiest county in the state, and Philadelphia County, which almost always comes in last, at 67th. We needed a plan to alleviate the nonmedical barriers of the patients we considered underserved.

In collaboration with our neighbor, Philadelphia College of Osteopathic Medicine (PCOM), we identified a solution that both addressed the immediate concern of preventing hospital readmissions and offered significant added value across numerous aspects of healthcare delivery and medical student education. We launched the Medical Student Advocate (MSA) Program in 2013.

About the Model

In the MSA Program, second-year medical students at PCOM can choose to volunteer a minimum of five hours each week with Lankenau Medical Associates, a primary care practice with a large population of high-risk patients. The students serve as patient advocates, working closely with the practice’s patient-centered medical home team to recognize and address nonmedical needs and barriers to care. Known as MSAs, these students leverage existing community resources to find solutions for issues such as access to care, health insurance, prescription coverage, transportation, utility assistance, health education, food assistance, child care, housing, personal care, and social support needs.

Each MSA works one-on-one with 15 to 25 patients over the course of the year under the guidance of a practice administrator and licensed social worker. This format allows each cadre of students—including 23 this year—to help hundreds of patients annually. In the first four years of the program, MSAs have served more than 900 high-risk patients and addressed more than 2,600 social needs.

The impact of the program is meticulously tracked using various metrics, including the level of patient satisfaction and how identified food sources influence a patient’s body mass index or blood sugar levels. In terms of the program’s original objective, we have seen a measurable decline in the rate of hospital readmissions and unnecessary emergency department (ED) visits at Lankenau since the MSA Program was introduced. That’s success.

One patient had 13 ED visits during the previous one-year period. An MSA connected with the patient and conducted a social needs survey, determining that the cost of copays impeded the patient’s ability to obtain asthma medication. The MSA worked with the social worker and case manager to get the copay reduced. In the six months since this intervention, the patient has not made any ED visits.

In addition to tracking ED utilization, we also track the number of needs that have been successfully resolved. In the past year, MSAs have successfully resolved over 80 percent of all needs identified. Tracking the types of needs that have been identified, we find that the most common needs for our patients include food access and transportation.

Expanding the Program

The MSA Program provides students with invaluable exposure to the socioeconomic determinants of health. With the experience and insight that they gain, MSAs have been noted to begin their third-year clinical phase better prepared and with substantially greater sensitivity to their patients’ concerns. This impression is verified by self-reports as well as by Lankenau faculty who serve as mentors during third-year student rotations.

The MSA Program is creating the next generation of healthcare professionals—physicians who know how to address both medical and social issues. Participants have cultivated a knowledge of population health and the patient-centered medical home concept, and they know how to ask the right questions to alleviate potential healthcare disparities.

As more organizations move into population health, the ability to improve outcomes for vulnerable patients is more critical than ever. The MSA model of providing advocacy to the underserved is easily scalable and should be replicable across the country. Lankenau has already extended our MSA Program to a federally qualified health center in West Philadelphia, embedding MSAs from PCOM in the center’s clinic. We also believe the program can move beyond the clinical setting into community arenas such as schools, libraries, and corner stores. This approach, too, is in the process of being implemented. 

The MSA Program is a high-quality, low-cost model that effectively addresses the complex social and economic issues faced by vulnerable patients, while helping medical students to become better physicians. We believe it can fundamentally change the future of health care.

Barry D. Mann, MD, is chief academic officer, Main Line Health, Wynnewood, Pa..

Chinwe Onyekere, MPH, is system administrator for graduate medical education, Main Line Health.

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