One in five Medicare patients who leave the hospital today will be re-admitted within 30 days according to a national study by The Centers for Medicare and Medicaid Services (CMS).
This statistic is bad news for patients, healthcare providers and American taxpayers, especially when more than three-quarters of these re-admissions are potentially preventable according to Charlene Frizzera, CMS Acting Administrator.
Chronic health problems for this generation are part of the problem. Repeated bouts of heart failure, lung disease and pneumonia take their toll on the elderly who do not bounce back as they once did. They come into the hospital sicker and sometimes leave sicker because of the pressure to discharge sooner than later because of Medicare reimbursement penalties. Many of them lack an established primary care physician for follow-up care and routine check-ups.
In an effort to solve this problem, CMS has taken a bold action. In April of this year, they announced that Metro Atlanta East was one of the 14 communities around the nation chosen to participate in the agency’s newly formed Care Transitions Project that seeks to eliminate unnecessary re-hospitalizations.
As expected, Newton Medical Center, along with other East Metro Atlanta hospitals, plays an essential role in collaborating with the Care Transitions Project. "Newton Medical Center constantly strives to improve the quality of patient care and wisely allocate healthcare dollars to maintain the financial viability of our hospital," explained James Weadick, CEO and Hospital Administrator.
The Care Transitions leader for East Metro Atlanta is the Georgia Medical Care Foundation. They will be offering guidance to the participating hospitals as well as monitoring the success of the project by watching the rates at which patients from this area return to the hospital.
Newton Medical Center’s Collaborative Discharge Planning/Care Transitions Team has been looking at discharge processes of all patients since January 2008. "The Care Transitions Project is not a one size fits all approach," explains team leader Jodi Brown, RN. "We must learn why our re-admissions occur here and address the underlying causes," she said.
The planning team works collaboratively with all healthcare providers in designing plans aimed at improving patient outcomes. According to Brown, who is the director of Newton Medical Home Health, discharge planning is a major focus at NMC and clinicians have taken several major steps.
For example, patients receive a folder filled with discharge instructions individually customized for them. Patients are educated on the importance of medication compliance, proper nutrition and regular physician check-ups. Registered nurses telephone patients to follow-up on their progress and facilitate at-home care.
"Our discharge planning is a collaborative process that can enhance all patients’ safe transition to either home or another level of care," says Floris Klein, Social Services Director at NMC. "We work with the patient’s doctor to keep the patient and their family informed about what to expect after discharge."
Brown indicates that plans are underway to set up support groups at NMC for patients with chronic illnesses such as congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD).
CMS has tracked re-admission rates for some time. These rates will be available to consumers later this year through the Hospital Compare Website at http://www.hospitalcompare.hhs.gov.
