Home Health Partnership Cuts Re-Hospitalizations in Half, Reduces Spending by 35%

Partnering with a home health provider to tackle social determinants of health has helped a Maryland hospital cut readmissions for its high-risk patients in half, while also reducing hospital spending for the same population by 35%.

Curbing re-hospitalizations has become a main focus for home health providers and hospitals alike as the U.S. health care system shifts toward a more value-based care model.

The aforementioned accomplishments are the result of a partnership between the University of Maryland St. Joseph’s Medical Center (UMSJMC) and Maxim Healthcare Services, which is based out of Maryland and provides home health, medical staffing and other services nationwide.


Through an opt-in program, UMSJMC uses Maxim’s non-medical community health workers (CHWs) to address social determinants of health for high-risk patients discharged from the hospital.

“You get one picture of a patient when you see them in the hospital, but when you get into the home is really when you see several layers of other dynamics that are also in play,” Andy Friedell, SVP of strategic solutions for Maxim, told Home Health Care News. “A lot of time those are the nonclinical barriers that keep people from following their care plan, and that’s kind of what [this] community health program is focusing a lot of time on.”

The program got its start four years ago following the creation of a readmission reduction incentive program in Maryland. In an effort to cut costs, UMSJMC — a nonprofit hospital just north of Baltimore — teamed up with Maxim.


Since the partnership began, participants in the free program have consistently fared better than nonparticipants in terms of readmissions.

For example, only 8% of patients who chose to participate in the program were readmitted to the hospital within 30 days of discharge. That’s compared to 18% of patients who opted out of the program, according to data from 2017 and 2018.

Meanwhile, at 90 days post-discharge, 23% of program participants had returned to the hospital, compared to 34% of non-program participants, the same data shows.

Besides keeping patients safely at home, the reduced readmissions have generated more than $3 million in savings over a two-year period, according to UMSJMC. Additionally, Maxim and UMSJMC evaluated the program’s financial impact by comparing per-patient hospital charges in the months before and after program enrollment: charges for each program participant decreased by 35% after 30 days and 9% after 90 days.

The program’s recent run of success is nothing new. The latest results come after 2016 data showed the partnership reduced readmissions among participants by more than 60% in its first 16 months.

The hospital-funded program has been so successful UMSJMC’s biggest challenge in implementing it has been convincing people to participate, Dr. Gail Cunningham, chief medical officer, told HHCN.

“Some patients either don’t want people coming to their home, believe they’ve got it all taking care of or some combination,” Cunningham said. “We haven’t been able to engage as many of our patients as we’d like to.”

Currently, about 30% of UMSJMC’s patients are eligible for the program because they’re identified as high-risk based on medical, psychological, functional or socioeconomic factors. However, only about half of eligible candidates opt into the program, Cunningham said.

“We continue to modify here and there with recruitment efforts to get more patients to agree,” she said.

Some examples include appealing to patients through family members or primary care doctors, as well as looking for new ways to refer people to the program.

How it works

Community health workers are largely responsible for the success of the program. Instead of providing medical services, CHWs address the behavioral and psychosocial needs of high-risk patients in-home.

That includes everything from transportation and housing to employment and access to medical services, all of which can be barriers to proper care following discharge from the hospital. CHWs also address other social determinants of health, harnessing community resources to keep patients healthy.

“They become very knowledgeable about the resources that are in the community, whether they’re church-related or grass-roots,” Cunningham said.

In one example, when a CHW saw her patient didn’t have a mattress, she turned to a local church, who helped the CHW obtain a bed for her client.

In turn, the hope is that improved sleep leads to improved conditions for the patient, as studies show lack of adequate sleep can affect judgement and lead to a host of health problems, such as diabetes, heart disease and premature death.

Addressing other social determinants — such as access to healthy food and lack of transportation — has also proven to have similar benefits.

In addition to helping patients, the partnership allows Maxim — which employs about 65,000 caregivers nationwide — to leverage the portion of its staff that don’t have nursing licenses, Friedell said.

“We saw the opportunity in those folks who do operate below the nursing-level licensure to step into more attractive roles doing this sort of work that is really tied to the value you provide to the system, rather than in and out hourly services,” he said.

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