The Southern Maine Area Agency on Aging, working with the 150-licensed-bed Southern Maine Medical Center in Biddeford, has been able to help patients proactively manage chronic illness in the community rather than in the hospital setting during crisis, says Helen Troy, SMMC's director of quality and case management.
The agency has helped patients and their families plan for inevitable structured custodial care settings so that such crucial decisions are not made urgently in yet another trip to the emergency department.
It used to be, Troy says, that it was "only after crisis after crisis, and re-admission after readmission, would it be decided that a patient could no longer return to their home. Now, we have a better opportunity in partnering with the CBO to prevent this from happening in crisis mode."
Troy says that procedurally, the hospital has made some important shifts to weave the program into daily operations. For example, staff are now guided by tools for better communication to community providers to assess patients' readmission risk, looking at key issues such as the number of drugs they're taking, past history of readmissions, psychosocial issues, and conditions that may categorize patients as "end-stage."
"It's in our patients best interest that hospitals be aware of services in the community and make all attempts to connect our patients to those resources as appropriate," she says.
In Southern Maine, as well as many other areas of the country, hospitals and their Area Agencies on Aging or other CBOs already had some informal working relationships to manage care transitions. But the dollars from this federal program enabled more formal routines to become standardized and accountable for outcomes, Troy and others say. Additionally, CMS will be monitoring each program's readmission success.
In Phoenix, Melissa Benfield, director of Healing@Home, which is working with four hospitals including John C. Lincoln, tells how psychosocial issues too often result in avoidable readmissions. Recently, a Medicare patient arrived home, only to become agitated over what she thought was a high-priced ambulance bill from the city. The transition coach talked with the patient for an hour in her home, reassuring her that the paperwork was a Medicare coverage notice, not a bill.
Shearer and Benfield describe another patient with a breathing condition who was supposed to get a nebulizer and oxygen, but the equipment had not arrived. When the transition coach showed up, she arranged to get what the patient needed in a couple of hours, avoiding what would surely have resulted in a readmission.
Benfield says that since Healing@Home began Feb. 1, coaches have helped 420 patients identified as high risk for readmissions.