Jocelyn Carter HS’06-’09, MPH’11 – On a Mission to Reduce Hospital Readmissions

For patients, leaving the hospital is a step in the right direction. But it looks different to Jocelyn Carter. In her mind, that day of departure starts a clock ticking: A study she did in 2017 showed that one in four hospitalized adults will land back in the hospital within a month.

During 10 years as an attending physician at Boston’s Massachusetts General Hospital (MGH), Carter has made it her mission to reduce avoidable hospital readmissions. In a new study, Carter and her team followed 550 frequently hospitalized inpatients at MGH. Half the patients received usual care, while half were paired with a community health worker. The health workers met with their patients before discharge and checked in afterwards via phone, texts, and visits. The workers coached patients on following care plans and getting to doctors’ appointments, provided psychological support, and helped people secure food, housing, and medicine.

Carter reports that connecting patients with a community health worker prevented half of 30-day readmissions. Among patients receiving usual care, 24.5% were re-hospitalized within 30 days. When community health workers stayed in touch with patients, the rate fell to 12.6%.

Fellowship-trained in Dartmouth-Hitchcock’s Leadership Preventive Medicine Residency, Carter is now using a $1.1 million National Institutes of Health career development grant to continue exploring roles for community health workers. “At this point, we’ve made the healthcare system hard enough to navigate that some patients living right here in the U.S. benefit from and increasingly depend upon support community health workers deliver,” she says in acknowledgment of community health work’s storied global health history. Due to the nature of the funding, study costs had to be kept quite low. “We did this on a dime!” says Carter: Just three community health workers supported 277 patients during the two-year study. When research funding ended in 2019, MGH operationalized funding and continued the program. “We’re a small but mighty team, and we’re going to be expanding,” Carter says.

She believes the time is right: In the past year, health workers outside the usual categories have taken on tasks like contact tracing and supporting testing. Carter says, “We can leverage this moment to show clearly how community health workers can contribute to the important work that clinical teams are doing.”

Written by Cathy Shufro