Hospitals are taking a close look at care transitions in preparation for reimbursement changes that will penalize hospitals for high readmission rates. To avoid Medicare cuts and penalties, hospitals across the country are experimenting with how to better care for patients after discharge.
Offer transition coaches
According to a recent study published in the Archives of Internal Medicine, a Journal of the American of Medical Association, programs designed to help older patients transition from the hospital to home can cut readmission rates. Hospitals that provided a transition coach for patients had a 12.8 percent readmission rate, compared to 20 percent for those without coaches.
New Jersey's Robert Wood Johnson University Hospital Hamilton in October launched a similar program, in which a transition coach visits patients at home, reports NJ Spotlight. The coach provides patients with a daily health record to monitor weight gain, track medication, write down questions for providers and map out personal goals. Although that responsibility has traditionally been on the healthcare provider, the transitional coach program encourages patients to actively manage their own care.
Implement post-discharge clinics
Some hospitals, including Boston's Beth Israel Deaconess Medical Center, are identifying patients who are likely to be readmitted and directing them to post-discharge clinics. At Beth Israel, providers at the post-discharge clinic, located near the hospital, check on patients to make sure they are taking medications and making follow-up appointments, reports Kaiser Health News.
Similarly, Barnes-Jewish Hospital in St. Louis recently launched its post-discharge program, called the Stay Healthy Clinic, for Medicare-eligible patients with chronic obstructive pulmonary disease, pneumonia, heart attack and heart failure. The Stay Healthy Clinic even goes as far as offering patients transportation to the clinic. Still, the program isn't a cure-all for one persistent challenge: Only half of patients show up to their appointments.
"We'll continue to try to tweak" the program, Barnes-Jewish Hospital Chief Medical Officer John Lynch said in the article.
Keep patients out of hospital from the start
Hospitals in areas that have high admission rates also have a high propensity for readmission rates, according a study published last week in the New England Journal of Medicine. The study suggests that more can be done in the beginning of patient care, that is, keeping patients out of the hospital from the get-go.
"I think the notion that we can do better at the point of transition are pretty obvious, but I think what this is saying is that it's really just a start of what we have to do," Dr. Arnold Epstein, one of the researchers at the Harvard School of Public Health, said in a National Journal article.
Researchers of the study don't discourage improvements in discharge planning, but they do suggest that Medicare and other payers reward hospitals for keeping patients out of the hospital altogether, according to the article.
For more information:
- read the NJ Spotlight article
- here's the Kaiser Health News article
- read the National Journal article
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