Preventing Hospital Readmissions Takes a Village

Remember the African proverb: "It takes a village to raise a child?" Maybe it takes a village to prevent hospital readmissions, too.

From Rockport to Yakima and from Detroit to El Paso, 30 community-based organizations are joining hands with hospitals, finally, in a communal effort to do just that, all funded by $500 million authorized by the Affordable Care Act for five years.

These CBOs are social support groups and Area Agencies on Aging, the type of quasi-government entities and non-profits historically known for home-delivered meals, transportation services, support, and counseling for seniors and the disabled. Now, these regional collaboratives are embarking on a variety of experiments to pick up the care of patients where hospital discharge planners leave off.

When I first wrote about the Community-Based Care Transitions Program last October, prospects looked grim. Projects were supposed to have started Jan. 1, 2011, but by fall none had been picked and few hospitals seemed interested.

Health and Human Services officials lamented the paucity of applications. Hospital officials complained they didn't even know who their senior services organizations were or what they did because they lived in different worlds. And how could they understand these medically fragile patients?