Group tries to reduce hospital readmissions
MADISON.com: Under the Affordable Care Act, Medicare penalizes hospitals that have too many readmissions, or admissions within 30 days of discharges, for patients with pneumonia, heart attack and heart failure.
But hospitals aren’t the only places that influence whether patients return. Nursing homes, home health agencies, home care agencies, aging agencies, hospices, pharmacies, ambulance services and others have an impact.
That’s a key motivation for the Dane County Community Transitions Coalition. Started in 2012, the group includes representatives from about 30 facilities or agencies that care for the elderly or chronically ill. The coalition meets monthly in an effort to improve transitions of care and keep readmissions down.
“We’re sending these people home and often they’re falling off the radar,” said Maria Brenny-Fitzpatrick, transitional care program director at UW Health and a co-leader of the coalition.
Preventing patients from returning to the hospital isn’t only about avoiding Medicare penalties. It’s also better for patients, Brenny-Fitzpatrick said. “Readmissions, on the patients, are very traumatic and very difficult,” she said.
One tool the coalition developed is an emergency medical information form that patients or loved ones can keep at home and give to paramedics and emergency room staff when needed.
The form includes major diagnoses, a list of medications and contact information for a care coordinator. It says whether the patient needs glasses or hearing aids to communicate or a cane or walker to walk.
Another information sheet, explaining supportive home care services, was developed by six agencies that provide such care in the county: BrightStar, ComForcare, Comfort Keepers, Home Instead, Midwest Home Care and Senior Helpers.
Other handouts focus on heart failure, when the heart doesn’t pump enough blood. One includes warning signs that should prompt patients to call a doctor or nurse, such as trouble sleeping or shortness of breath with regular activity. The handout also includes “red zone” symptoms requiring a 911 call, such as chest pain or a fainting spell.
In a related effort, Safe Communities of Dane County and the Wisconsin Institute for Healthy Aging plan to offer a Living Well workshop next spring focusing on heart failure.
Living Well workshops “build participants’ confidence in their ability to manage their health condition to maintain active and fulfilling lives,” according to the institute’s website. For more information about the workshops, contact Lynne Robertson, Safe Communities’ outreach specialist, at 608-836-9810 or firstname.lastname@example.org.
Dane County’s readmission rate, of about 37 per 1,000 Medicare beneficiaries, hasn’t changed much in recent years. It’s lower than the state and national averages but higher than two-thirds of counties in Wisconsin.
I wrote an article in November about a study at UW Hospital of whether an experimental drug can protect healthy seniors whose brain scans show signs of risk for Alzheimer’s disease.
Now UW Hospital is part of a different study to see if another drug might slow the progression of the disease in people with mild to moderate Alzheimer’s. Patients who are ages 55 to 85 and have been taking the drug Aricept for at least six months might be eligible.