PATient Navigator to rEduce Readmissions

PATient Navigator to rEduce Readmissions

Staying out of the hospital is valued by patients and their caregivers. Their interests converge with those of hospitals now that high 30-day readmission rates for some conditions place hospitals at risk for financial penalties from the Centers for Medicare and Medicaid Services. This study focuses on developing and testing a program that combines a community health worker (lay patient advocate, acting as a "Patient Navigator") and a peer-led telephone support line to improve patient experience during hospital to home transition.

Inclusion Criteria:

1. Age 18 years or older on date of hospital admission
2. Hospitalized at the University of Illinois Hospital, Chicago
3. Admission diagnosis, per treating physician, of pneumonia, COPD, sickle cell disease, heart failure, or myocardial infarction
4. Receive medical care on an inpatient medical service

Exclusion Criteria:

1. Unable to understand and speak English
2. Unable/decline to give informed consent
3. Previous participant in PArTNER
4. Planned transfer to another acute care facility
5. Planned discharge to facility other than home (e.g. long term care facility)
6. Currently on hospice or plans to discharge home to hospice
7. Current plans to leave against medical advice