Community Health Worker Intervention to Improve Post-Hospital Outcomes

Community Health Worker and Certified Peer Specialist Intervention to Improve Post-Hospital Outcomes

This study tests an intervention designed to avoid 30-day readmissions following a medical hospitalization by patients who have co-occurring mental illness. The Intervention is delivered by community health workers in the inpatient setting and 30 days following hospital discharge to the community.

This study will test the efficacy of a brief intervention delivered to adults with co-occurring medical and mental health conditions by community health workers designed to avoid 30-day readmissions following medical hospitalization. Adult inpatients of a university hospital will be randomly assigned to the intervention plus services as usual versus services as usual alone, and assessed at baseline and 30 days following discharge. Chi square will be used to assess the primary outcome of admission within 30 days of discharge and changes in patient activation, mental health symptoms, medication adherence, and perceived competence for health maintenance. Also examined will be study condition differences in post-discharge inpatient service utilization and cost.

Inclusion Criteria:

• receiving inpatient treatment for chronic medical condition
• evidence of a mental health diagnosis
• age 21- 60 years
• expected to return to community residence
• residing within a 30-mile radius of the hospital
• expected to remain in hospital for 2 or more days
• able to provide informed consent

Exclusion Criteria:

• terminally ill
• unable to communicate in English
• expected to be discharged to skilled facility or nursing home
• participating in another transitional care intervention
• hospitalized for behavioral health disorder