After being hospitalized, seniors face big hurdles in following up on their care. As many as 20 percent of Medicare patients return to the emergency room within a month of being released.
But with a push from the new health-reform law, trial programs in Central Florida and across the state are tracking patients after their discharge papers have been signed to make sure they don’t wind up back in the hospital for another costly stay.
The interventions are showing promise: A pilot program at two Miami hospitals, for example, showed that the average hospital readmission rate was reduced dramatically with visits by nurses, who remind patients about checkups and drug refills, combined with free, nutritious meals, which are hard for seniors living alone to prepare.
The preliminary results were presented this week at a Florida Council for Aging meeting in Orlando.
“We can’t just hospitalize, discharge and say good luck,” said Peggy O’Neill, vice president of Nutrition Services for Independent Living Systems, a company that provides social services in Florida. “It’s costly, and quality of life is very poor.”
The Miami trial used nurses as “coaches” to keep patients out of emergency rooms in the weeks following their discharge.
Researchers enrolled 118 seniors at two hospitals to get the coaching visits plus deliveries of food for a month.
Nurses visited homes two days, seven days, 14 days and 30 days after discharge to ask patients if they’d scheduled appointments with their doctors and to make sure they were taking medications as prescribed.
The number of patients readmitted within 30 days dropped from 23.3 percent to 2.7 percent, said Jeffrey King, senior vice president for clinical operations at Independent Living Systems.
Even hot meals by themselves had a beneficial effect. Among patients who received meals without coaching, 13.6 percent were readmitted within the next month.
“It’s not just the meal,” King said. “It’s people delivering the meal, talking to the patient.”
Florida Hospital and Orlando Health, Central Florida’s major hospital systems, have similar efforts, though the results haven’t yet been measured.
About 60 Medicare patients discharged from Florida Hospital have been eligible for the Hospital and Home Transition Program, which began in March. It offers delivery of meals and groceries, rides to appointments and light housekeeping, said the program’s director, Steve Paquet.
A warm meal can be a big help for seniors who can’t drive after a hospital visit, or who live alone or with disabled spouses, Paquet said.
“They want to be home and independent, but they’re not up to the energy level to cook. If you can have that nutritious meal delivered, it makes a difference.”
Orlando Health is subcontracting with social workers to connect patients ” especially those without insurance ” to social programs such as Meals on Wheels.
“Oftentimes, patients end up coming back because they’re not following up on treatment,” said Scott Clark, the administrator of transition services for Orlando Health. If a patient is homeless and comes in with a wound, Clark said, he might not know where to turn for follow-up care and will be back in the emergency room within a week.
The two hospital giants have used the same principles for several years in following up on heart-failure patients. A clinic at Florida Hospital offers education and help to patients with congestive heart failure, one of the biggest reasons for hospital readmissions. One man with heart failure had visited the emergency room two or three times with massive swelling in his legs and shortness of breath. The clinic quickly diagnosed the problem: He had stopped taking his medication because he wasn’t sure how to get it refilled.
The pilot programs are being offered free to patients, in part because hospitals are under pressure to develop better ways of keeping elderly patients from returning. Starting in October 2012, hospitals’ Medicare reimbursements will be reduced if they have high readmission rates.
The trick for hospitals is making the right balance between avoiding costly readmissions and recognizing that some patients really do need to come back to the ER.
“There’s a point to which you don’t want to push this,” said Rich Morrison, vice president of government affairs for Florida Hospital. “You’re not going to completely eliminate readmissions, especially with older people. We don’t want to cause problems for the patient.”
Article by: Marissa Cevallos, Orlando Sentinel
Marissa Cevallos can be reached at [email protected] or at 407-540-3531.