Avoiding hospital rebound

WASHINGTON - Talk about unnecessary misery: One in five Medicare patients winds up back in the hospital within a month - even worse, one in four patients with heart failure.

A major push is under way around the country to cut rehospitalizations, in part by arming patients with simple steps to keep their recovery on track - like getting past harried receptionists for quicker follow-up doctor visits, and reducing medication confusion.

Less than a year into a Medicare-sponsored "Care Transitions" project in 14 states, participating hospitals already are seeing readmissions start to inch down, says Dr. Barry Straube, chief medical officer of the Centers for Medicare & Medicaid Services.

One of those projects, in Baton Rouge, La., sends health coaches to five area hospitals to guide high-risk patients through discharge and check how they're faring through that critical first month. Of the first 145 patients coached so far, only seven had to be rehospitalized.

The key: Support, so that weakened seniors don't backslide merely because they couldn't get a timely doctor's appointment or had no ride to the drugstore to pick up a prescription, says coach DeeAnn Broussard with Louisiana Health Care Review, a quality-improvement company leading the project.

Consider her heart failure patient who sought a doctor's appointment, saying he couldn't sleep. The doctor's booked all month and his receptionist doesn't realize the man has heart failure and really was describing shortness of breath when he laid down, due to worsening fluid build up.

"He needs to say, 'I can't sleep because I can't breathe,"' explains Broussard, teaching a phrase that cues receptionists to squeeze patients in. A quick drug change might get rid of that fluid and avert a rehospitalization.

Rehospitalizations ought to be handled with the same urgency as an epidemic, says Dr. Harlan Krumholz of Yale University. He helped the American College of Cardiology begin a "Hospital to Home" program this fall, signing up hundreds of hospitals to share solutions with the goal of cutting heart patients' readmissions by 20 percent within three years.

"Somehow this idea of one in four people landing back in the hospital in a month is treated as business as usual, that it's part of being sick in America. It doesn't have to be that way," he says.

The top risks:

• Medication problems. Patients on a dozen or more drugs forget which ones they're supposed to toss when given new ones in the hospital, or can't afford the new ones, or have no way to pick them up.

• Not getting a follow-up doctor's visit within a week of discharge. Waiting longer is proven to increase rehospitalization. Yet even if patients have a primary care doctor, getting a rapid appointment can be tough.

• Not realizing early signs of trouble and knowing what to do about them.

Rehospitalizations aren't just bad for patients, but for taxpayers, too. They're costing Medicare $17 billion a year, a recent study estimated. Hospitals make more money when patients have to return.

Last summer, Medicare started posting hospital readmission rates for the three worst conditions - heart failure, heart attack and pneumonia - on its Web site, peer pressure for hospitals to improve. And either as part of Congress' pending overhaul of the health care system or its own regulations, Medicare eventually hopes to cut payments for rehospitalizations in ways that encourage better upfront care.

"Even the best hospitals have room for improvement," says Straube, who hopes to expand the Care Transitions program to all states in a few years.

As for the payment debate: "Shame on us for paying you for things that should really in many cases not have happened," he says.

Not every rehospitalization is preventable, says Yale's Krumholz, and there's no one solution that will help every hospital lower the rate.

When discharging heart patients, "you hold your breath a little bit," he says. "They're vulnerable, they're tired, they heard messages from a bunch of different people."

Nor is it an issue just for Medicare. At Duke University Medical Center, trauma nurse Jo Ellen Holt takes photos with patients' own cell phones to guide them through the home care required to avoid infection and rehospitalization.

It started with a man in his 50s whose arm was rebuilt with muscle and skin from elsewhere on his body after a machine accident. The discharge nurse cleared the man to leave, assuming his wife could clean his arm and change his bandages - only to have Holt discover right before the couple left that the woman couldn't stomach the task. So Holt snapped a photo of each step, helping the man remember the order of each solution and ointment and type of gauze. One-armed, he cleaned his own wound fine.

"I want to help them be independent," Holt says.

• Lauran Neergaard covers health and medical issues for The Associated Press in Washington.