Readmissions and Community-Based Support
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Saints Medical Center, a 157- licensed-bed hospital in Lowell, Mass., is one of five hospitals that joined Merrimack Valley Care Transitions program that began Feb. 1. Since then, Helene Thibodeau, the hospital's vice president of outpatient services, says the project "has led us to see that we need to look beyond the four walls that surround our hospital, and make sure that we're including the community-based organizations to facilitate good transitions for our patients."
Janet Liddell, who is quality and patient safety manager for Saints Medical Center, says that other readmission prevention efforts were already under way. But participation in the community care transition program has enabled the medical center to "add a transition coach to our discharge process. It's not something we were able to do before, and it extends the work we were able to do to the patient's home. It offers a softer landing for the patient and improves transitions to the community that way."
The process has helped prevent readmissions from skilled nursing facilities as well, a source of "a good portion" of the medical center's readmissions, Liddell says. "When patients are transferred to skilled nursing homes or long-term care facilities, those patients will be handed off to the transition coach" in those facilities.
For patients discharged to their homes, care transition coaches spread out the patient's medications on the kitchen counter and compare each with the discharge instructions. "Many times they've picked out discrepancies," Liddell says. "Or it may mean that when there's a question, they call the patient's primary care provider right then and get clarification."
The Merrimack Valley program also has a mental health component, with transition coaches who are specifically trained to deal with depression and anxiety in Medicare patients, which Liddell says has frequently led to avoidable readmissions.
Saints was acquired on July 1 by Lowell General Hospital, which plans to continue the program, Thibodeau says.
"There's just not time to deal with all these things while the patient is still in the hospital," says Rosanne DiStefano, executive director of Elder Services of the Merrimack Valley, which has so far completed 1,600 patient assessments under the program. "The patient is not at the point where they're ready to absorb it all; this has to be done over a period of time." Observing the patient in his or her home has also uncovered safety issues that can lead to injuries, she says.
Administered by the Centers for Medicare & Medicaid Services, the CBCTP was supposed to be launched in January 2011. But initially, most hospitals—whose participation is essential—were unenthused.
Hospitals and their trade group representatives were skeptical that regional 501(c)(3) staff had enough medical or polypharmacy expertise to prevent readmissions with transportation, meal programs, and home visits. And why should the CBO receive all the funds when the hospitals get the financial hit from readmissions penalties, they asked.
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