This exploratory study aimed to address the effectiveness of a lay-health worker (LHW) model in addressing social needs and readmissions of high-risk patients admitted in a rural community hospital. A quasi-experimental study design assessed implementation of a LHW model for assisting high-risk patients with their post-discharge social needs. Outcome measures included 30-day hospital readmissions rates during a 4-month baseline period compared with a 6-month post-implementation period. The LHW intervention involved assessment and development of a personalized social needs plan for enrolled patients (e.g. transportation and community resource identification), with post-discharge follow-up calls. There was a 47.7% relative reduction of 30-day hospital readmissions rates between baseline and intervention phases of the study. Simple regression analyses demonstrated a 56% decrease in odds (90% confidence interval 0.20-0.98) in being readmitted within 30-days among those in the intervention phase compared with those in the baseline phase. Once adjusting for education, transportation cost and anxiety symptoms, there was a 77% decrease in odds among those exposed to the LHW program. LHWs offer an effective hospital-based model to improve transitions in care from the hospital setting, especially those at high-risk with persistent social needs.