How to keep older patients from returning to the hospital

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 – and financial risks. 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.

The Affordable Care Act 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. But Schmidt participated in a successful, pioneering model that began 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.

Learn more in my column today at Reuters Money.