Navigating the Health Care System

If you or a loved one has ever been in the hospital for a serious condition, the last thing you want is a fast return trip.

But that's what happens to 1 in 5 patients covered by Medicare, the health insurance program for people 65 and older, a major study found. Hospital readmissions within 30 days are costly for Medicare and for patients. These readmissions total about $17 billion each year. Being readmitted to the hospital can also slow down a patient's ability to recover or cause new problems.

The good news: We know how to prevent many readmissions. And we have tools to help hospitals do a better job.

Starting next month, Medicare will prod hospitals to improve their practices. Hospitals with high readmissions for three conditions (heart attack, pneumonia, and heart failure) will get paid less than hospitals with fewer preventable readmissions.

Why do many older patients need to go back to the hospital so soon after they've left?

Many of them are high-risk patients. They may be frail, have chronic conditions, or be unable to get to their follow-up medical appointments.

Another reason is that hospitals tend to transfer patients to less costly settings once their condition is stable. Getting follow-up care at a skilled nursing facility or at home is a good option, and one many patients prefer. But this care needs to be carefully managed, so things like medical tests or appointments are completed.

To meet that goal, nearly 50 groups around the country have begun working to improve the care for high-risk Medicare patients leaving the hospital. The Community-based Care Transitions Project draws on the experience of local groups such as the Area Agencies on Aging, the Visiting Nurses Association, and others. This project was created under the Affordable Care Act.

In addition, research funded by the Agency for Healthcare Research and Quality (AHRQ) has been used to create tools that help hospitals reduce readmissions.

For example, a project at Boston University Medical Center called Project RED found that patients who left the hospital knowing how to deal with their after-care needs were less likely to be readmitted or to go to the emergency room later.

Key elements of Project RED include—

• Educating patients about their diagnosis while they're in the hospital.
• Making appointments for needed follow-up tests.
• Making sure patients understand how to take their medicines.
• Calling patients two to three days after they leave the hospital to address any problems.

More than 260 hospitals now use parts or all of Project RED to prevent readmissions.

A guide for patients developed by AHRQ called Taking Care of Myself: A Guide for When I Leave the Hospital is based on the findings from Project RED. It gives patients an easy-to-understand plan for what to do when they leave the hospital. The guide is available in English and Spanish.

Another AHRQ-funded program educates patients and families about using medicines correctly when patients leave the hospital.

Project BOOST (Better Outcomes for Older adults through Safe Transitions) also helps hospitals and outpatient settings work together on patients' care plans.

Helping patients improve their health once they leave the hospital is not easy or automatic. The new effort by hospitals to prevent readmissions is a big step in the right direction. You can help by learning what you should do when you or your loved ones are in the hospital.

I'm Dr. Carolyn Clancy, and that's my advice on how to navigate the health care system.

Resources

Agency for Healthcare Research and Quality
Taking Care of Myself: A Guide for When I Leave the Hospital
https://www.ahrq.gov/qual/goinghomeguide.htm

Project RED (Re-Engineered Discharge)
https://www.ahrq.gov/qual/projectred

Improving Hospital Discharge Through Medication Reconciliation and Education
https://www.ahrq.gov/qual/pips/williams.htm

Community-based Care Transitions Program: Centers for Medicare and Medicaid Innovation
http://www.innovations.cms.gov/initiatives/Partnership-for-Patients/CCTP/index.html?itemID=CMS1239313

Jencks SF, Williams MV, Coleman EA. Rehospitalizations among Patients in the Medicare Fee-for-Service Program. N Engl J Med 2009; 360:1418-1428.