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Being hospitalized for an illness today is traumatic. I would not recommend that you go by yourself. Take a family member or friend to advocate for you. Many things could happen and you want someone there to watch out for your best interest. Don’t get me wrong, hospitals are incredible organizations that provide valuable life saving services. However, things go wrong and mistakes happen. So play it safe, bring an advocate. If you don’t have one, good luck.

When you make it through the acute hospitalization, then you are discharged to the next level of care. That may be to your home with home health care, or to a rehabilitation facility, or other level of care like a nursing home. Whatever level of care, the transition can be hazardous to your health.

According to Medicare data, one in five patients (20%) discharged from a hospital is back in the hospital within 30 days. Unplanned and unnecessary re-hospitalizations cost the health care system billions of dollars every year—accounting for roughly one-fifth ($17.4 billion in 2004) of Medicare hospital costs—and they are a marker of poor discharge planning, inadequate follow-up care and lost opportunities in the management of chronic illness. Lowering unnecessary hospital return rates needs to be given a focus by lawmakers and health systems.

The Obama administration estimates that $26 billion could be saved over 10 years from an overall reduction in the hospital-return rate – and under the new federal Patient Protection and Affordable Care Act, the Centers for Medicare & Medicaid will use a 30-day cutoff to start penalizing hospitals with higher-than-expected rates of readmissions, starting in 2012. Let me repeat that – under the new health reform law, hospitals will have to go beyond the discharge door and help facilitate smoother transitions and improved quality care or get financially penalized. Therefore, we will see reduced readmission rates AND reduced Medicare expenses.

Hospital readmission rates not only hold the potential as an area for drastic cost-savings, but they serve as a key marker of quality care. Low readmission rates signal strong transitions, well-functioning discharge planning, exemplary follow-up care and, overall, a healthier, better-adjusted patient.

Many health care providers are already feeling the anxiety from current or proposed cutbacks in state and federal funding. Now is the time for hospitals, rehabilitation centers and other inpatient settings, as well as payers, to take a hard look at their current practices and work on improving their clinical coordination models. Inpatient services need to work with outpatient health and community services. Health care silos maybe great cost centers now, but poor in overall quality for the person and health care costs.

The Center for Healthy Aging has collaborated in the past with Washoe County Senior Services and Adult Services, Renown Health Services, and the various state divisions of the Department of Health and Human Services to provide more continuous transitional services that include home and community living services. Unfortunately that program did not continue. We need to reactivate it and enhance that system design and development.

One model to adopt in Nevada is what Dr. Eric Coleman from Colorado has developed – the Care Transitions Program. This program has significantly reduced readmissions to hospitals, resulting in reduced Medicare expenses while simultaneous increasing the quality of care. The aim of the Care Transitions Program is to support patients and families; increase skills among healthcare providers; enhance the ability of health information technology to promote health information exchange across care settings; implement system level interventions to improve quality and safety; develop performance measures and public reporting mechanisms; and influence health policy at the national level. It works! They have the research to prove it.

The Center for Healthy Aging is proposing to the state, county, and other stakeholders to modify the current approach and adopt what Colorado is doing. The change would include interventions to elders being discharged from the acute hospital that would include such components as:

  • Medication self-management: Patient is knowledgeable about medications and has a medication management system such as the Medication Therapy Management program available;
  • Use of a dynamic patient-centered record: Patient understands and utilizes the Personal Health Record (PHR) to facilitate communication and ensure continuity of care plan across providers and settings. The patient or informal caregiver manages the PHR;
  • Primary Care and Specialist Follow-Up: Patient schedules and completes follow-up visit with the primary care physician or specialist physician and is empowered to be an active participant in these interactions;
  • Knowledge of Red Flags: Patient is knowledgeable about indications that their condition is worsening and how to respond; and a
  • Transitional Health Coach to facilitate the continuity and quality of care.

The Transitional Health Coach could be a trained volunteer that would serve as an advocate for the elder that would help assure the best care possible. They would serve that capacity in the hospital if there were no family/friends, but more importantly upon discharge and transitioning to various care settings after hospitalization. They would make sure that medications were reviewed by a “geriatric certified” pharmacist and managed appropriately; that self-management and self-direction were encouraged and put into place; the PHR was utilized; that follow-up visits to primary care and specialist physician were accomplished; and changes in condition were addressed.

It is time that we insist that our health care system be responsive and coordinated. We cannot afford to have a fragmented, broken system with costs off the chart. By employing some evidence based changes, such as Coleman’s Care Transitions Program, we can cut costs by reducing unnecessary re-hospitalizations that cost Medicare over $17 billion and improve the quality of care at the same time. Certainly, adopting programs like this would be “adding life to years.”

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