Community health workers combat readmission.

M R ALBERTS IS THE classic " frequent flyer. " At age 60 years, he has chronic obstructive pulmonary disorder, anxiety, and chronic pulmonary emboli. Formerly a computer network engineer , he has been unemployed since 2010. He was admitted to the hospital 4 times within the first 6 months of 2011. His cumulative charges to Medicaid were $82 952— substantially higher than the na-tion's median income and 8 times Mr Alberts's income. Each year, 24.6 million Ameri-cans are hospitalized. 1 Over 14% of all patients 2 and nearly 20% of Medi-care patients 3 are readmitted within 30 days of a prior hospitalization. In 2004, unplanned readmissions cost $17.4 billion to Medicare alone. Low-income African American patients like Mr Alberts are up to 43% more likely than their higher-income white counterparts to find themselves back in the hospital within weeks of discharge. 4,5 As a result, the cost of care for these disadvantaged patients is high, as illustrated by the population of low-income patients who are dually eligible for Medicare and Medicaid. Dually eligible individuals cost twice as much as other Medicare beneficiaries largely because they are 4 times as likely to be readmitted to hospitals for ambulatory care– sensitive conditions. 6 Reducing preventable readmis-sions is a major component of the Affordable Care Act; beginning in 2013, hospitals that remain in the highest 25th percentile of readmis-sions will face a penalty of up to 1% of all Medicare base inpatient reimbursement. 7 Figuring out how to do better for low-income individuals like Mr Alberts is imperative if we are to control health care costs— and improve quality. Why is Mr Alberts a health care frequent flyer? Multiple comorbidi-ties, complex chronic diseases, and polypharmacy are the most commonly described patient-level factors that drive hospital readmis-sion. 8 There have been several successful interventions geared at improving the transition from hospital to home for medically complex patients. 9 Typically they employ clinical personnel to facilitate medication reconciliation, symptom management, and care coordination. 9 Yet poor health status is only part of the reason for the readmission of patients like Mr Alberts. Besides disease burden, 3 factors perpetuate the revolving hospital door for low-income patients: lack of access to medical resources such as a regular source of care, competing socioeconomic issues such as homelessness or food insecurity, and social isolation. Mr Alberts explains his situation in his own words: My family is scattered and …