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Preventing Hospital Readmissions Takes a Village

Cheryl Clark, for HealthLeaders Media, April 12, 2012

CBO workers try to anticipate avoidable complications, such as malnutrition, falls, symptom confusion, or medication misuse that can occur if the patient didn't understand their dosage or couldn't get to the doctor.

If problems do arise, there are follow-up calls and referrals to coordinate additional services in a way that hospitals rarely have enough staff to do.

"Sometimes it really does take looking into someone's fridge to see, do they have food when they get home from the hospital?" says Cathie Berger, director of the Atlanta Area Agency on Aging, one of the first seven collaboratives approved. "Somebody needs to be checking back, and following that patient home," if only to see if the patient could easily trip and fall.

"A lot of people don't understand what their needs are until they get home," says Robert Mapes, manager of community and agency relations at AgeOptions, a collaborative approved to work with six Chicago area hospitals. "They may find that their bed at home is a lot lower than their hospital bed and it's tougher to get in and out of and they need help. Or they don't realize how much standing is required to cook your own meal at home."

The Centers for Medicare & Medicaid Services pays the CBOs directly. Rates vary, but one organization indicated the rate was $200 to $300 per discharge, or more depending on the scope of work. CMS officials wouldn't comment, saying it separately negotiates all rates.

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