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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.

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.

Rush, though, began its own program two years ago because its staff had long suspected that the detailed discharge plans they sent home with patients—covering follow-up doctors’ appointments, prescriptions and health services offered in their communities—were often ignored. The hospital’s rates of readmission for heart attack and pneumonia patients, at about 20 percent, are in line with the national average, according to CMS data. Its readmission rate for heart patients, at 27.8 percent, is slightly higher than the national average of 24.5 percent.

“The frustration was knowing how broken the system was once they went home,” says Madeleine Rooney, a social worker with Rush. “They got home, and they were on their own. That can be scary and overwhelming for people.”

A few calls, a big difference

Under Rush’s Enhanced Discharge Planning Program, hospital social workers begin to make follow-up calls to patients—their average age is 74—within a few days of their discharge. Patients over the age of 65 are referred to the new program if they live alone and take a number of medicines, or have a history of hospitalizations.

Of the 1,248 patients called between March 2007 and April 2009, about 60 percent needed help, according to the program’s records. The cost to Rush? About $60,000 a year, most of which went to pay the salary of one additional social worker. The program calls for social workers to coordinate services available in the community. Often just small pieces of information about services, or help pursuing them, are all that is needed.

Meals and wheels

When the program began, Rush found that many patients had trouble scheduling their follow-up doctors’ appointments or getting transportation to the doctor’s office. Some couldn’t afford to fill all their prescriptions. Others reported delays in visits by a home health care agency or delivery delays of equipment such as wheelchairs or oxygen. One man with special dietary needs was signed up to get home-delivered meals but never got his food. The meals were being delivered to the wrong address.

What the new Rush program does, says Anthony Perry, a geriatrician at Rush, is look beyond medical treatments to see what the patients will need once they have left the hospital’s care. “We only see a piece of that patient, and we sometimes don’t know what all the issues are” when the patient returns home, he says.

Perry says social workers are best equipped to make the follow-up calls, especially to older patients, because they are familiar with the community services and can cut through bureaucratic thickets.

Readmission rates cut by half

Rush doesn’t yet have complete results on whether its program is reducing hospital readmissions. Other studies, however, have shown this kind of out-of-hospital help can cut readmissions by about half. At a University of Pennsylvania hospital, where nurses made home visits and arranged follow-up visits and community services, just 28 percent of patients were back in the hospital within 26 weeks. In the control group, 56 percent had to be readmitted.

This fall, Rush will offer the same sort of assistance before people even leave the hospital. Doctors and social workers will spend more time with the patients and their families or caregivers, going over their medications and discharge instructions and contacting their personal doctors to provide medical updates and arrange appointments. All this attention to the patient is part of a pilot program that involves Rush and 29 other hospitals across the country. It’s called Project BOOST—Better Outcomes for Older adults through Safe Transitions—and is sponsored by the Society of Hospital Medicine.

Fixing a fragmented system

Rooney, the Rush social worker, says better care doesn’t require a lot more people or money. What’s needed are better, more effective ways to use the people, programs and money already there.

That’s a sentiment that patients like 84-year-old Elizabeth Schickel can understand. Eye problems had forced her to give up driving. After her surgery in April, Schickel wasn’t sure how she would get back to Rush for her follow-up appointment. A Rush social worker told her about free rides available from the city. “That was really helpful,” Schickel says. “You don’t know those things unless someone calls you and tells you.”

Donald Musil, who has been in a wheelchair since a fall last year, didn’t need the help of a Rush social worker—but his wife did. Susan Musil says she was emotionally drained from caring for her 73-year-old husband. She worried that her stress could affect his health. When she asked the rehabilitation center treating her husband to help her find counseling, the staff gave her the only number it had—for a crisis hotline. A Rush social worker, however, found a counseling agency that specialized in therapy for caregivers and even checked back with Musil after her first appointment.

“When she called,” Musil says, “it was just a breath of fresh air.”

As for Katherine Ellis, she, too, had a fresh start thanks to the Rush program: She hasn’t been back in a hospital since she left Rush almost seven months ago.

Phuong Ly is a freelance writer based in Chicago.

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