Community Health Workers (CHWs) Enhance Transition of Care to Reduce Readmissions

 

Every hospital readmission is more than just statistics and data – it disrupts lives, renews stress for patients and families, and signals missed chances for better continuity of care. According to CMS (2024), thirty-day readmission rates are a key quality measure, often reflecting “quality of hospital care, poor discharge planning, and ineffective coordination of post-discharge services.” Evidence shows that reducing preventable readmissions requires multiple interventions, such as patient education, discharge checklists, medication reconciliation and review, post-discharge follow-up, and addressing social determinants/drivers of health (SDOH) and disparities (CMS, 2024).

The period after discharge, or transition of care (TOC), is a critical time for these interventions. Patients may leave hospitals or other settings with new medications, complex instructions, unanswered questions, unmet social needs, or limited abilities. Missed follow-up visits, confusion about care plans, or unaddressed social challenges often lead to readmissions. Community health workers (CHWs) play a vital role in bridging these gaps. By leveraging shared culture and language, CHWs build trust, simplify instructions and address health literacy, coordinate follow-ups and transportation, provide phone or home check-ins, and connect patients to SDOH resources such as housing, food, or utility support.
Preventing readmissions is not just a medical process – it is a human one. CHWs support individuals where they live, work, and recover, helping ensure safe transitions, reducing avoidable hospital stays, and providing the connection and support patients and families need.  

Practice Transformation Institute CHW Training Program prepares CHWs to do this and more.

• To learn about the program, visit us at https://transformcoach.org/learning-solutions/community-health-worker-chw-program/
  

• To listen to our Informational Session Zero about the CHW Program, click here: https://youtu.be/fvf-qmY66k8?si=B_1FhqDCvtS_dlgy
  

• Don’t miss out! Registration for our next CHW training is now open. To register, click here: https://cvent.me/OvBWe0
  

September 25, 2025 – February 19, 2026

Thursdays | 9:00 AM – 4:00 PM (Live Virtual)

Learners will receive 0.6 IACET CEUs per session

Reference:
CMS Office of Minority Health. (2024). Guide for Reducing Disparities in Readmissions. https://www.cms.gov/about-cms/agency-information/omh/downloads/omh_readmissions_guide.pdf