How transitional care can manage even the most imperfect patient

He's probably one of the greatest men I know, and he's probably also the world's worst patient. He's my grandfather, a senior cancer survivor, who also just recently underwent knee surgery.

Even for all the love that I have for him, he's the imperfect patient. You know the type; he stops taking antibiotics when he's feeling better even though there are a few pills left. He combines different medications into one bottle to "save room" in his medicine cabinet. He has misplaced his Social Security card, state ID, and who knows where his insurance card is. He has limited English-speaking skills, especially when it comes to medical jargon. He travels out of the country regularly, but he doesn't drive. And in his golden years, he's becoming more forgetful, which makes it difficult for him to schedule follow-up appointments or call the doctor for lab results.

He's survived hunger, communism, and cancer, but he can't seem to get to the doctor on the right day at the right time.

To make matters worse, he has multiple providers who don't share information with each other about his medical history, medications, and conditions.

The family tried to remedy the gap in information sharing by once considering Google Health's personal records. But we didn't like the idea of handing over a medical history to Bill Gates, Al Gore, Steve Jobs, or whoever else owns the Internet these days. (I suspect that reasoning from the public led to Google's Health ultimate demise.)

Instead, we've taken a team approach to helping Granddad manage his care. That means my parents, my aunt and uncle, my sisters, my cousins, and I, who are stretched out along the East Coast, take turns helping out when and where we can. We translate instructions, fill up his medicine box, book and drive him to his appointments, and call for results.

Although we're all happy to do it, helping to manage someone's care can quickly turn into a full-time job. Many other "imperfect patients" don't have family support, which is why I am fascinated with the idea of transitional care programs. Although they go by a variety of titles, transitional care coordinators are dedicated patient advocates with medical backgrounds who help people like my grandfather navigate the healthcare system after leaving the hospital.

Some of the leading hospitals in the country are experimenting with the concept and showing impressive results. For example, a recent study in the Archives of Internal Medicine found that programs with "patient coaches" aimed at transitioning older patients from hospital to home cut down on readmissions. Researchers at Quality Partners of Rhode Island, Providence, found that the odds of readmission with coaches were significantly lower (12.8 percent readmission rate), compared to those without coaches (20 percent).

Similarly, the University of California, San Francisco, found that transitional care programs with nurse coordinators helped reduce readmissions of older heart failure patients by 30 percent and helped save Medicare $1 million per year, according to researchers.

In addition, the registered nurses at the transitional care program at Renaissance Medical Management Company in Philadelphia yielded a 31 percent reduction in commercial readmissions and a 10 percent reduction in Medicare readmissions for its network patients.

With more studies sure to follow about the benefits of transitional care and reimbursements tied to readmissions, I applaud the providers and institutions doing such innovative work to improve patient care and even help curb healthcare spending. I hope that more patients like my grandfather will benefit from improved care management across the continuum. - Karen (@FierceHealth)