How a hospital used social workers to cut readmissions

Mt. Sinai social workers go 'above and beyond' to keep patients healthy

New York City's Mount Sinai Hospital has begun integrating social workers into its overarching strategy to curb readmissions among Medicare patients, and early data show the effort has slowed the hospital's revolving door, Bloomberg's Shannon Pettypiece reports.

Mount Sinai created the program in response to an incentive system set up under the Affordable Care Act that rewards hospitals for keeping patients healthy and penalizes those with excessive patient readmissions. Mount Sinai also is one of more than 250 Medicare ACO participants now being reimbursed based on the cost of caring for some of its patients, rather than fees for procedures and tests.

"This is not just one more of those 1990s' initiatives around cost containment, this is really a trend around changing the way you deliver care," says Karoline Hilu, a senior director at The Advisory Board Company. "This is going to be what hospitals need to do to survive in this current era of health care," she adds.

The inner workings of Mount Sinai's effort to fight readmissions

Over the past three years, more than 600 Mount Sinai patients have been assigned to one of 27 social workers focused on keeping patients out of the hospital. Under the program, administrators use a multimillion-dollar computer system each morning to vet every patient in the hospital; the system relies on an algorithm that scores how likely each patient is to be readmitted based on a range of factors, such as medical history and recent admissions.

The scores are shared with a group of social workers tasked with contacting the patients determined to be at highest risk. They will meet with each patient for 75 minutes, trying to detect any "underlying reason that people are coming back to the hospital," says Maria Basso Lipani, program director of Mount Sinai's Preventable Admissions Care Team. "We really will do anything and everything."

Oftentimes, this involves enrolling patients in a special program for at-risk patients that enable them to gain access to a regular doctor or nurse practitioner. Social workers also help ensure that patients attend follow-up appoints, enroll in a mental health program, or arrange a delivery of free meals tailored to the individual's medical conditions.

Pettypiece writes that Mount Sinai's social workers often go above and beyond the usual service for their patients. In one case, a social worker went to the Department of Motor Vehicles to lobby on the patient's behalf for a driver's license, which is needed to obtain health insurance. In another case, a social worker arranged to get mold removed from the apartment of patient with respiratory conditions.

Early signs of success

The program reduced admissions 43% and cut ED visits 54% during a pilot run from September 2010 to May 2012, Mount Sinai says. Hospital officials estimate that the decision to target high-risk patients saved $1.6 million in medical costs over a six-month period.

Based on the initial results, Mount Sinai was awarded a five-year federal grant to pay for 20 social workers focused on treating the hospital's Medicare patients. In addition, insurer HealthFirst pays for three social workers for its members, and Mount Sinai itself pays for four more to target patients with Medicaid coverage and private insurance.

Hilu says most hospitals have developed similar programs that are focused on preventing readmissions. "This is going to keep coming … it is only just beginning," she says (Pettypiece, Bloomberg, 9/25).


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