As the nation focuses on how to cut the cost of so-called health care reform, maybe it’s time to pay attention to demonstrated methods for improving care while reducing costs that are not yet supported by Medicare and other payers. We cannot afford the system we have and changing it should be on the top of the agenda for anyone who wants to extend coverage of health care to all and improve health outcomes.
 

For example, many readers of this blog will have had the experience of being a patient or family caregiver for someone who is older and has multiple chronic health problems that periodic become acute and require hospitalization. Once discharged from the hospital, the patient and caregiver often feel at a loss for how to manage some of the problems that can arise even within hours of discharge. A study published in the New England Journal of Medicine in April of this year reported that one in five Medicare patients who are discharged from a hospital will be readmitted within 30 days. That number keeps increasing with time, so that by the end of one year, about half of these patients will have been readmitted. This is costing the nation an estimated $17 billion.
 

Mary Naylor is a nurse researcher at the University of Pennsylvania who has spent more than 20 years developing and studying what she calls a Transitional Care Model (PDF). Under this model of care, an advanced practice registered nurse (APRN) goes into the hospital when high risk (for readmission) patients are admitted. The APRN assesses the patient and family caregiver, clarifies the plan of care and coordinates the input of sometimes multiple health care providers, prepares the patient and family caregiver for discharge, then makes a home visit within the first 24 hours after discharge and continues to work with the patient and family caregiver for up to 90 days post-discharge. Naylor says this is more than “care coordination.” She sees it as an opportunity to help patients and families rethink how they approach and manage their care. The APRN will even go with the patient and family caregiver on a follow up visit to the physician’s office to model how to make the best use of this time.
 

Naylor isn’t the only one doing this work. Eric Coleman of the University of Colorado at Denver Medical Center and Chad Boult of the John Hopkins University Health Institute have developed variations on the Naylor model. All show that hospital readmission rates decrease, money is saved and health outcomes improve in some way.

Now AARP has worked with Congress to develop a Medicare Transitional Care Act (H.R. 2773/S. 1295) that has been introduced into both houses of Congress. The Act calls for Medicare to pay for a transitional care benefit, first for high-risk patients and then, if the outcomes of this first phase are satisfactory, for low- and moderate-risk patients. It’s long overdue. I now believe it to be unethical for hospitals to discharge patients knowing that they don’t have the knowledge and resources to help them through this difficult transition to home. To read about the details of the bill, go to http://www.govtrack.us/congress/billtext.xpd?bill=s111-1295. The bill needs advocates who will urge Senators and Representatives to sign on as co-sponsors or, at the very least, support this important legislation.