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Hospitals Help Their Patients—at Home

To reduce readmission rates, hospitals help discharged patients with rides to the doctor and home-delivered meals.

nurse pushing patient in wheel chair

— OJO Images/Getty Images

Katherine Ellis shuffles slowly through her home, wearing bright red bedroom slippers, green shorts and a T-shirt. A retired cook, she is a friendly, open woman who enjoys people. But because of her arthritic knees, Ellis, 71, rarely ventures beyond the door of her tiny apartment on Chicago’s West Side, a home crammed with ceramic knickknacks and framed photographs of her children and grandchildren. When Ellis does leave home, too often it’s to be admitted or readmitted to the hospital for heart problems and viral infections.

Last year she was in and out of the hospital at least four times. She’s lost track of the exact number. So when she was admitted to Rush University Medical Center last March to have a pacemaker implanted, Ellis was almost resigned to returning for another stay. But a few days after her discharge, she received a phone call from a social worker at Rush: Did she need any help?

The call came just in time. Ellis says she was confused about how and when to take her various medicines. She felt dizzy and weak and wondered whether the drugs were to blame. After that conversation, the social worker called the community home-health agency that works with Ellis. A nurse there was asked to review Ellis’ medicines and organize them in a pillbox. “I’ve got it down pat—I know what to take now,” Ellis says confidently.

The social worker also worked with the agency to help coordinate doctors’ visits.

“I was surprised,” says Ellis. “I never had nobody call me before to try to help.”

Billions spent on hospital readmissions

Traditionally, hospitals haven’t followed their patients’ progress after they’ve been discharged. But high readmission rates have been linked to spiraling—and unnecessary—health care costs, prompting hospitals like Rush to start pilot programs to give patients the help they may need when they first return home.

A study published in the April New England Journal of Medicine reports that, currently, about one in five Medicare patients returns to a hospital within 30 days of being discharged. And that’s expensive.

At Rush, for example, the typical hospital stay for a Medicare patient is six days at a cost of $18,000 to Medicare.

Nationally, readmissions cost Medicare $17.4 billion in 2004. That means helping patients avoid return trips to the hospital will benefit not only the patient, but the nation’s health care system as well, says Mark Williams, M.D., of Northwestern University’s Feinberg School of Medicine and coauthor of the Medicare study.

Many readmissions, he points out, can be prevented with a bit of “damage control.” About half of the patients in his study who were readmitted to the hospital, for example, never saw a doctor after they were discharged.

Penalizing hospitals for ‘frequent fliers’

Readmission rates have become such a concern that both President Barack Obama’s budget proposal and the health care reform bills in Congress call for changes in how hospitals are paid. Those with a large number of patients who are “frequent fliers” would have their Medicare payments cut. Congress also is considering legislation that would create a new Medicare benefit that would extend Medicare coverage to services designed to help ease the patient’s transition from hospital to home, a move that can be abrupt, confusing and even frightening.

How frequently patients return to the hospital after treatment for heart attacks, heart failure and pneumonia is an indicator of how well the hospital did the first time around, according to the Centers for Medicare & Medicaid Services (CMS). The federal agency is sponsoring 14 projects nationwide to study how transitional care can reduce readmissions.

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