Keeping people from being sent back to the hospital


By Al Norman

Have you ever known someone who went into the hospital, came back home, and then within a month or so, was readmitted?

These kinds of “readmissions” are more common than most people realize. According to a recent federal report, re-hospitalization is a “frequent, costly, and sometimes life-threatening event.” Given that Medicare beneficiaries comprise 46 percent of hospital admissions, hundreds of millions of dollars in Massachusetts could be saved by preventing readmissions.

Researchers estimate that 20 percent of Medicare beneficiaries who are discharged from hospitals are readmitted within 30 days and 33 percent are readmitted within 90 days. The national fiscal impact to Medicare as a result of unplanned hospital readmissions was $17.4 billion in 2004. In addition to these financial costs, re-hospitalization can increase the risk of health complications, resulting in greater disability for consumers.

Research has shown that 28 percent of hospitalizations can be avoided. As many as 40 percent of the hospital trips from nursing homes are not necessary, because they could have been handled as an outpatient visit, or the consumer could have remained in the long-term care facility, or their conditions did not warrant inpatient care.

According to a state report released last January, Massachusetts shares many of the care transitions challenges that the rest of the country faces. The report identified “care fragmentation” as a key problem in the Massachusetts healthcare system. “Patients and families are unassisted as they navigate across different providers and care settings,” the Care Transitions report said, “and state leaders believe that poor communication and lack of clear accountability for a patient among multiple providers lead to medical errors, waste, and duplication.”

Research in recent years on care transitions activities shows that when consumers receive coaching after they are discharged from a hospital, they have lower re-admittance rates than those who had no coaching at all. Here in Massachusetts, a group of 70 care managers who work for Aging Services Access Points were trained in April in “The Care Transitions Intervention (CTI),” which is a four-week hospital-to-home care program during which patients with complex care needs and family caregivers work with a coach. The program includes a hospital and home visit and three follow up phone calls, in which the coach focuses on:

•Supporting the consumer in developing and maintaining a personal health record;

•Helping the consumer and family members to understand when and how to obtain follow-up care; and

•Role playing with patients to ask the right questions to the right health care providers to get their needs met across the various follow-up care settings. In this model, consumers and their family members play a more active role in managing the patient’s condition and developing self-care skills. They learn about medication self-management, how to pay attention to symptoms and recognize warning signs that trigger the need for care. Families are also given instructions on how to respond to various health alerts.

A study of the Care Transitions program showed the program cost was $196 per patient. Another study reported that consumers who were coached saw an estimated annual cost savings — above the cost of the intervention — of $844 per patient.

Under the new Patient Care Protection Act, the federal government has offered $2.5 million in competitive contracts for up to six states to expand their “Care Transitions” efforts.

Massachusetts should be one of the states applying for this important care transitions initiative to keep people living at home, and from having to be re-admitted to the hospital.

Al Norman is the executive director of Mass Home Care. He can be reached at 413-773-5555, or at