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When Henriette Arzewski first met her diabetic client, he was a virtual prisoner in his third-floor walk-up apartment. Recently discharged from the hospital, he suffered circulatory problems and had vision problems. With help from Arzewski and others, he got the eye surgery he needed, obtained coverage for his diabetic medications, was transported to medical appointments, received home-delivered meals and got transferred to senior housing, where he has become part of a supportive community.

Arzewski, a retired social worker, is a health navigator at St. Luke’s-Roosevelt Hospital in New York City, where she’s participating in a pilot project aimed at helping older adults from being readmitted to the hospital. It’s showing promising results.

In 2008 the pilot program operated by ReServe and Continuum Health Partners assigned nine health navigators to work with 22 clients who had recently been discharged from the hospital. The navigators were enlisted to help clients live independently, with assistance from Laurie Hyman, coordinator for ReServe's Health Navigator Program, and hospital social workers.

Initial results show:

• Twenty of the 22 patients, or 91 percent, have remained out of the hospital.
• Typical client support lasted three to six months, depending on the client’s needs.
• The health navigators worked an average of 5.5 hours per week.
• The clients had an average age of 77.5, while the navigators’ average age was 67.3.
• The estimated labor cost per client was $1,980.

The program has proven so successful that ReServe is training six more health navigators to address the increased referral load.

ReServe piloted the program in 2008 at Beth Israel Hospital and St. Luke’s-Roosevelt Hospital in New York City in response to research that found costly hospital readmissions for Medicare patients are common but often preventable, if adequate community-based support is available.

According to a study published in the April 2009 edition of the New England Journal of Medicine, one-fifth of hospitalized Medicare beneficiaries are readmitted to hospitals within 30 days of discharge, and one-third are readmitted within 90 days.

ReServe works with hospital staff to identify at-risk older adults and match them with health navigators who typically make weekly home visits and regular calls to their clients. They usually help three to five clients at a time and are supervised by a program coordinator.

“ReServe’s health navigator program addresses two dire needs in our communities: one of affordable continuity of care for recently discharged, isolated, frail elderly, and the other for active retirees, who want to make a meaningful contribution and use the skills acquired over a lifetime,” said Mary Bleiberg, executive director of ReServe.

ReServe is a nonprofit organization based in New York City that matches qualified retirees with part-time jobs in private nonprofits and government agencies. ReServists receive a stipend of $10 per hour for doing flexible, part-time work. Partner organizations pay ReServe $15 per hour to cover the cost of the stipend, plus administrative fees and payroll services. For more information, visit ReServe’s Web site.