Photo: Corbis

Readmission rates have become such a concern that both President Barack Obama’s budget proposal and the health care reform bills in Congress call for changes in how hospitals are paid. Those with a large number of patients who are “frequent fliers” would have their Medicare payments cut. Congress also is considering legislation that would create a new Medicare benefit that would extend Medicare coverage to services designed to help ease the patient’s transition from hospital to home, a move that can be abrupt, confusing and even frightening.

How frequently patients return to the hospital after treatment for heart attacks, heart failure and pneumonia is an indicator of how well the hospital did the first time around, according to the Centers for Medicare & Medicaid Services (CMS). The federal agency is sponsoring 14 projects nationwide to study how transitional care can reduce readmissions.

Rush, though, began its own program two years ago because its staff had long suspected that the detailed discharge plans they sent home with patients—covering follow-up doctors’ appointments, prescriptions and health services offered in their communities—were often ignored. The hospital’s rates of readmission for heart attack and pneumonia patients, at about 20 percent, are in line with the national average, according to CMS data. Its readmission rate for heart patients, at 27.8 percent, is slightly higher than the national average of 24.5 percent.

“The frustration was knowing how broken the system was once they went home,” says Madeleine Rooney, a social worker with Rush. “They got home, and they were on their own. That can be scary and overwhelming for people.”

A few calls, a big difference

Under Rush’s Enhanced Discharge Planning Program, hospital social workers begin to make follow-up calls to patients—their average age is 74—within a few days of their discharge. Patients over the age of 65 are referred to the new program if they live alone and take a number of medicines, or have a history of hospitalizations.

Of the 1,248 patients called between March 2007 and April 2009, about 60 percent needed help, according to the program’s records. The cost to Rush? About $60,000 a year, most of which went to pay the salary of one additional social worker. The program calls for social workers to coordinate services available in the community. Often just small pieces of information about services, or help pursuing them, are all that is needed.

Meals and wheels

When the program began, Rush found that many patients had trouble scheduling their follow-up doctors’ appointments or getting transportation to the doctor’s office. Some couldn’t afford to fill all their prescriptions. Others reported delays in visits by a home health care agency or delivery delays of equipment such as wheelchairs or oxygen. One man with special dietary needs was signed up to get home-delivered meals but never got his food. The meals were being delivered to the wrong address.

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