Coaches smooth transition home from the hospital

This fall, the federal government will cut Medicare payments to hospitals that have higher-than-expected readmission rates. Several medical centers in the region are testing pilot programs to prevent that financial penalty.

 

Frequent fliers are great customers in the airline industry. In health care, bounce-backs are a bad thing – costly and often preventable.

One of those working to prevent them is Lynette Newkirk, director of case management who helped develop the COACH — Collaborating Options Across the Continuum of Healthcare — program at South Jersey Healthcare in Vineland, N.J.

Newkirk says her hospital staff is communicating more with insurance providers, nursing homes, rehab centers and other extended-care facilities.

“Everybody is in this together. They are telling us we need to get together and work out smooth transitions of care for our patients, smooth handoffs,” Newkirk said. “Everybody on the same page for this patient, and not functioning in silos anymore.”

South Jersey’s coaches expedite follow-up visits for patients with a primary care doctor. When patients make that call, sometimes needed care never happens.

“They may go home and not call initially, wait a couple of days,” Newkirk said. “They may call and say, ‘I’m calling to make an appointment with the doctor’ but not mention they were in the hospital, and those appointments can be delayed.”

The COACH program begins with a case manager providing a bedside consultation before discharge, then there’s an in-home visit within 24 hours to check prescriptions.

“We are reviewing the list that we have and we are asking the patient to pull together all the medicines in their home and make sure that it matches up,” Newkirk said. “We also look in their cabinet and talk about the type things that they are eating that may contribute to them having a relapse in their condition.”

About 300 patients have participated so far, and the readmission rate for the group has dropped by 18 percent.

Newkirk says she reorganized her department — and reduced the number of managers — to free up more people to work directly with COACH patients. For now, the program is focused on heart attack, pneumonia, chronic obstructive pulmonary disease, chronic bronchitis and heart failure.

Newkirk thinks the program is a success, but says without additional funding help it would be too costly to expand to other patients.

Avoiding bounce-backs is part of the federal health law plan to lower costs. A national study from 2003 and 2004 found that one in five Medicare patients landed back in the hospital within 30 days of discharge.