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By Mark Miller
CHICAGO (Reuters) - Ann Marie Schmidt had knee replacement surgery last month. The operation was for an old injury that made walking painful, but the 71-year-old resident of Temple, Texas, has other, more serious conditions. She suffers from neuropathy (nerve pain), scoliosis and meningioma - a type of benign brain tumor.
Schmidt is the kind of high-risk patient Medicare worries about as a candidate to land back in the hospital after surgery. Nearly one in five Medicare patients discharged from the hospital is readmitted within 30 days, at a cost of $17 billion every year to Medicare, according to the Centers for Medicare & Medicaid Services.
Aside from the expense to Medicare, readmission presents serious health risks for patients.
"It's a long list," says Dr Eric Coleman, associate professor of medicine and a geriatrician at the University of Colorado Health Sciences Center. "But the big ones include infection, falls that cause fractures, medication errors, confusion or delirium." Patients also run the risk of losing physical strength and becoming frail during hospital stays, which can needlessly send them into nursing care.
There is also a financial risk for patients - under Medicare, patients pay a $1,184 deductible for each hospitalization. And sometimes patients are readmitted on what is called "observation status," which means they are outpatients in the eyes of Medicare and must shell out for co-pays; and, Medicare Part D often will not cover drug costs administered in the hospital for such patients.
Patients like Schmidt - or their caregivers - often find themselves grappling with the complexities of caring for themselves after release from the hospital. Many feel they do not understand their discharge instructions, and managing multiple medications for an array of conditions is especially perilous.
The Affordable Care Act (ACA) includes funding to test a variety of models for improving care transition, with the goal of reducing readmissions by 20 percent by the end of this year. More than 100 healthcare organizations are participating in the tests. Schmidt participated in a successful, pioneering model that Coleman began developing a decade ago called the Care Transitions Intervention (CTI).
CTI is a four-week program following a hospital discharge that has proven to reduce readmissions by 50 percent or more. It involves a visit from a healthcare coach while the patient is still in the hospital, a home visit and three follow-up phone calls. The focus is on helping patients and their caregivers to manage medications, and training them to recognize "red flags" that might indicate a developing problem that could lead to readmission.
In most cases, patients wind up being their own care coordinators, but they need to have the tools to be effective. "Patients get confused," Coleman says. "They get home and all the pill bottles from before their hospitalization are still there. They need a system for sorting through it. But they also need to learn how to recognize red flags. What do you do if your condition is worsening? There's one answer to that if it's a weekday afternoon, and a different answer at 2 a.m. on a Sunday."
CTI has nearly 900 hospital and health-plan partners around the country. Schmidt was treated at Scott & White Hospital in Temple. It is part of a larger nonprofit healthcare system serving Central Texas and owned by Scott & White Healthcare, which has been testing the CTI on a group of nearly 800 high-risk Medicare hospital patients.
Scott & White's overall readmission rate for Medicare patients is about 18 percent; but among patients who completed the CTI process, readmission rates have been slashed to just 4 percent, says Alan Stevens, director of the system's Center for Applied Health Research.
Numbers like that should be music to the ears of hospital administrators. While the ACA includes pilot funding to test new community-care models, it also punishes hospitals that experience readmission rates deemed too high. Hospitals with unacceptably high readmission rates will see a 1 percent reduction in Medicare payments for all of their patients this year.
The government crackdown will accelerate in 2014 and 2015, with higher penalty rates levied for an expanded number of conditions. This year, the penalties are expected to generate $300 million in fines from hospitals.
Stevens says programs like CTI have enormous potential to save money and improve patient outcomes. "Despite what we think we can do with hospital care, we know the most important transitional care is a combination of formal and informal care from family, friends and the patient herself.
"Any time you're in the hospital - no matter how good it is - you're at risk for medical errors and complications, and preventable infections. The better quality of care is to stay out of the hospital if at all possible."
The challenge is to get hospitals and clinics on board. "They're really not comfortable thinking about what they need to do in the community or connecting with patients in their homes," Stevens says.
Schmidt is at home and recovering nicely after a 10-day rehabilitation stay in a skilled nursing facility. "I really don't think I'll be going back in the hospital," she says. "I'm going to try hard to not go back - who wants that?"
For more from Mark Miller, see (http://link.reuters.com/qyk97s)
(Editing by Lauren Young and Matthew Lewis; Follow us @ReutersMoney or at http://www.reuters.com/finance/personal-finance.)
(The writer is a Reuters columnist. The opinions expressed are his own.)