You'd think that once you're discharged from the hospital, you're no longer sick. Right? But a 2009 study by the Centers for Medicare and Medicaid Services found that in 2004, one in five Medicare beneficiaries was readmitted to the hospital within 30 days, usually for pneumonia or urinary tract infections contracted through improper follow-up care.
The outlook was even grimmer a year out: Within 365 days, 70 percent of patients were either back in the hospital or dead. (The number was slightly lower for people who had had surgery: 53 percent.) All these boomeranging patients cost Medicare $17.4 billion.
In the interest of improving their patients' health and, of course, saving money, Barnes Jewish Hospital and Washington University Medical School has conducted a study of their own: One randomly-selected group of patients discharged from the general medicine service (that is, not surgery) would receive the standard level of care. Another group would work with a nurse transition coach for the first 30 days after leaving the hospital.
"Often patients who don't qualify for home care services still need assistance in the immediate period following hospital discharge," Sandy Graff, the nurse who coordinates the study for Washington University, said in a press release. "Our goal is to assist these patients in understanding the actions that are needed to avoid an unnecessary return to the hospital."
The nurse transition coach visits the patient at home during the first two days after discharge in order to make sure all the patient's medicines are in order, that the patient knows how to take them, and that the patient has scheduled a follow-up appointment with his or her primary-care doctor. Sometimes the patient has trouble getting the necessary medicines, and the coach helps out with that, too.
"Medications are expensive and often there are co-pays involved in obtaining them," said Dr. John Lynch, chief medical officer at Barnes and one of the principal invesigators of the study. "Patients experience significant barriers to adherence to the medical regimen when they can't afford medications or don't have transportation to and from the pharmacy, even though they want to comply with what has been prescribed."
Because it's a university hospital, Barnes has a higher readmission rate then average. It provides more specialized and cutting-edge medical procedures, and many of its patients lack the means to pay for proper medicine and follow-up care. Or as Lynch puts it, "We have a number of patients living in areas of the city that do not have the type of health care resources that other patients in the region may enjoy."
The study has yet to show any definite results, but Lynch hopes that if the study does prevent lower hospital readmission rates, Medicare and other insurance providers will start picking up the cost of sending out nurse transition coaches.
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