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Studies: Postdischarge Care, Delivery System Transformation, Health Equity

These recent journal articles, selected by our team of researchers, highlight important issues related to postdischarge care, delivery system transformation, and health equity.

Postdischarge Care

Feasibility and Evaluation of a Pilot Community Health Worker Intervention to Reduce Hospital Readmissions International Journal for Quality in Health Care (subscription required)

Community health workers (CHWs) provide services that improve patients’ self-management skills and access to care, including health education, patient advocacy, interpreter services, navigation of community and medical services, and social services. A pilot study at America’s Essential Hospitals member Cambridge Health Alliance found that hospital readmission rates were lower among patients that received help from a CHW and suggested that hospital-based CHWs may improve transitional care for vulnerable populations. Results were published in the April issue of the International Journal for Quality in Health Care.

“Missing Pieces”— Functional, Social, and Environmental Barriers to Recovery for Vulnerable Older Adults Transitioning from Hospital to Home Journal of the American Geriatrics Society (subscription required)

Few studies have explored how the transition from hospital to home may contribute to fragmented care, adverse drug events, and readmissions for elderly patients with low socioeconomic status. This study, conducted by researchers from the University of California, San Francisco and published in the August issue of the Journal of the American Geriatrics Society, identified the following three missing pieces in care for this population:

  • functional limitations and difficulty with mobility and self-care
  • social isolation and lack of support from family and friends
  • challenges from poverty and the environment at home

The results suggested that postdischarge interventions to address these challenges may be needed to reduce readmissions.

Follow-Up of Gestational Diabetes Mellitus in an Urban Safety Net Hospital: Missed Opportunities to Launch Preventive Care for Women Journal of Women’s Health (subscription required)

Women with gestational diabetes mellitus (GDM), which is a type of diabetes that develops only during pregnancy, are at significantly greater risk of getting type 2 diabetes mellitus, but researchers from Boston Medical Center found only 23.4 percent of GDM-affected women receive a glucose test by six months postpartum. This study, published in the April issue of the Journal of Women’s Health, concludes that low glucose testing rates among GDM-affected patients indicate a critical missed opportunity to provide preventive care to women.

Delivery System Transformation

Trial to Examine Text Message–Based mHealth in Emergency Department Patients with Diabetes (TExT-MED): A Randomized Controlled Trial Annals of Emergency Medicine (subscription required)

Low-income, inner-city patients with diabetes are increasingly using emergency departments for acute and chronic care. In a study published in the June 2014 issue of Annals of Emergency Medicine, researchers from the Keck School of Medicine at the University of Southern California, Los Angeles found that a text message-based intervention program improved medication adherence and decreased ED utilization for this population.

Early Experience of a Safety-Net Provider Reorganizing into an Accountable Care Organization Journal of Health Politics, Policy and Law

Since the passage of the Affordable Care Act, several essential health care providers have used the accountable care organization model to improve quality and efficiency and address financial shortfalls. This May 2014 study from the Journal of Health Politics looks at successes and drawbacks of Cambridge Health Alliance’s accountable care organization.

Health Equity

Academic Health Centers and Care of Undocumented Immigrants in the United States: Servant Leaders or Uncourageous Followers? Academic Medicine

Undocumented immigrants are currently ineligible for federally funded health care programs and are prohibited from purchasing coverage through the health insurance marketplaces (exchanges). In this commentary published in the April issue of Academic Medicine, authors from the University of California, Davis aim to dispel misconceptions about undocumented immigrants’ use of health services and suggest that academic health centers need to refocus on social responsibility to all people in their communities.



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