A federal pilot program that’s helped keep local high-risk Medicare patients at home and healthy while reducing hospital readmission rates ended this week, but not the community resolve to help patients from returning to the hospital in the first 30 days after release.
“The concern is (hospital) readmission rates will go right back to where they were,” said Teresa Michielli, the care services director who oversaw the hospital transition program at Aging and Long Term Care of Eastern Washington. “It’s really important to get people during this critical period.”
One in every five Medicare patients sent to the hospital ends up returning within a month. Bridging Care Across the Northwest started in 2013 and was free to patients with Medicare A and B who were admitted to Spokane’s Providence hospitals – Sacred Heart Medical Center and Holy Family Hospital – and Kootenai Health in Coeur d’Alene.
The goal was to provide patients – the elderly and disabled often with chronic diseases such as diabetes – a smooth transition between hospital and home. The 30-day program served between 200 and 400 people a month, helping them understand their medications, schedule follow-up appointments with doctors, arrange transportation and look for “red flag” symptoms. Basically, it was like having a one-on-one health coach, Michielli said.
About 2.6 million seniors are readmitted to the hospital within 30 days of their initial stay, costing $26 billion every year, according to the Centers for Medicare and Medicaid Services. The goal is to reduce hospital readmission rates by 20 percent.
“I appreciate this program,” a Spokane woman in the program said in a recent review. “It feels like someone has your back after you leave the hospital.”
The woman didn’t want to share her name, but told the Bridging Care team she was reluctant to talk to her doctor about shortness of breath, headaches and fatigue from a previous condition and different hospital visit. After a few visits with the coach, she had the confidence to write a list of questions and visit her doctor. She no longer felt like she had to “soldier through.”
The Eastern Washington and North Idaho program was successful, reducing readmission rates by 3 percent during the last reporting period and at times as much as 9 percent, said Lynn Kimball, the executive director of ALTCEW.
Yet nationally, the Centers for Medicare and Medicaid Services didn’t view the 34 federal pilot programs across the country as cost-effective enough to keep going until the funding ran out in January 2017, Kimball said. So the pilots are ending before the $300 million allocated by the Affordable Care Act is spent.
Monday was the last day for Bridging Care Across the Northwest, while some other pilots across the country will operate through June. In North Idaho, the Area Agency on Aging oversaw the program for Kootenai Health patients. The handful of coaches and staff members will now work for ALTCEW’s Health Homes program.
Traditionally hospitals were alone in trying to reduce readmission rates. Yet experts now believe having community is key to helping people manage their recovery so they don’t have to return to the hospital. The pilot programs encouraged the community, especially non-medical health workers, to work together to improve quality, improve patient experience and reduce cost.
Even though this particular program is done, Kimball said they will use what they learned and hopefully incorporate that knowledge into other service programs. The agency is already talking with the hospitals and other community providers.
“Nobody wants to go back,” Michielli said. “We’re not letting the skills we learned go to waste.”
Providence communications director Elizabeth DeRuyter said its on-site care coordinators are already doing much of the same work as Bridging Care, following up with patients – all patients not just those with Medicare – after they are released from the hospital.
“This pilot targeted at a very specific group of people,” DeRuyter said, adding the hospitals are working to help all patients transfer to their homes. She said Providence is always willing to work with community-based providers.
Hospital readmission rates, especially for Medicare patients, are in the spotlight and Congress is encouraging hospitals to have transition programs that monitor patients for 30 days after they leave the hospital.
Since 2012, hospitals have been penalized for having high readmission rates. The Hospital Readmission Reduction Program, a provision in the Affordable Care Act, requires Medicare to reduce payments to hospitals that have readmission rates that exceed national average.
In August, Kaiser Health News reported that the majority of the nation’s hospitals were penalized with 2,592 hospitals receiving lower payments for every Medicare patient who stays in the hospital, readmitted or not. That’s a combined loss of $420 million.
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