Healthfirst and JASA help to reduce hospital readmission for older adults

The Challenge

Older adults face significant readmission risk following hospital discharge, especially if they have been diagnosed with multiple chronic conditions and/or present unmet social needs, such as food insecurity and social isolation.

Our Goal

To better support members over age 55, reduce readmissions, and improve member health and wellness.

The Healthfirst Solution​

Through the JASA care transitions program, we targeted Healthfirst members over age 55 across five underserved ZIP codes in Brooklyn and Queens. Members were engaged as soon as possible after discharge and received help with managing medications, coordinating post-discharge care, and meeting socioeconomic and behavioral health needs for 30 days.

Population Health Improvements

Members enrolled in JASA’s care transitions program were more likely to have two or more visits with their primary care physician (62.3% vs. 54.1%) and were much less likely to not access PCP care (1.6% vs. 9.8%) compared to matched controls in the study.

Takeaway

The JASA care transitions program showed that engaging with members after discharge helps improve the likelihood of primary care follow-up. However, there was no statistically significant impact on readmissions. Healthfirst recognizes this as an area that needs additional research and new interventions.

This program was seeded by grant funding from the Samuels Foundation.