Personal touches help patients at risk for readmission

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Just as the government is ramping up efforts to curb readmissions, hospitals are working to keep discharged patients from bouncing back to the hospital.

Marin General and Novato Community hospitals in California, for example, are part of Advanced Care Transitions, one of the 30 Centers for Medicare & Medicaid Services pilots nationwide, aimed at reducing Medicare costs by $8.2 billion by 2019, Marin Independent Journal reported. The two hospitals target about 700 of the highest-risk Medicare patients with heart failure, pneumonia, diabetes and other chronic conditions.

The county plans to hire two new nurses as transitional coaches, who will meet with patients before discharge and post-discharge at home. Not only are the hospitals improving the discharge process, but they also are making sure patients take their medications during the post-discharge home visit and through patient education.

Having someone the hospital can refer patients to for follow-up after they return home "is something we haven't had in the past," Mary Strebig, a spokesman for Novato Community Hospital, said in the article.

Like the Marin hospitals, Glendale, Calif., hospitals are similarly targeting high-risk patients with heart attack, congestive heart failure and pneumonia, as one in five of those high-risk patients readmit to the hospital within 30 days, according to Glendale News-Press.

The Glendale Healthier Community Coalition created a task force to look at the annual 40,000 patients discharged from area hospitals. The task force not only looks at provider reasons to readmissions but also the patient's situation, such as whether the patient is homeless or foreign-born, which might affect their ability to care for themselves.

"Even going 12 to 18 hours without their medication could already put them on a trajectory for readmission," Bruce Nelson, director of community services at Glendale Adventist Medical Center and cochair of the task force, said in the article.

Nelson said case managers at hospitals are helping with tasks, such as transportation to doctors' offices and refilling prescriptions, as well as coordinating care across the continuum, including skilled nursing facilities.

CMS this month launched two programs, the Community-based Care Transitions Program and Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents. CMS has dedicated $500 million to Partnership for Patients funding. The Partnership's two goals are reducing hospital readmissions by 20 percent over a three-year period and reducing harm in hospital settings by 40 percent.

For more information:
- read the Marin Independent Journal article
- here's the Glendale News-Press article

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