Transition of Care in Burr Ridge

One of the hottest topics in the health care industry today is the problem of preventable hospital readmissions. According to the Robert Wood Johnson Foundation, readmissions cost Medicare $26 billion each year. Of that amount, $17 billion is spent on preventable readmissions.

To combat these costs, starting in 2012, the Centers for Medicare and Medicaid (CMS) began reducing the amount of reimbursements it pays to hospitals that have high 30-day readmission rates for patients initially hospitalized for three conditions: heart failure, heart attack and pneumonia.

In a proposed rule issued in April 2013, CMS added two new conditions — replacements of the hip or knee and chronic obstructive pulmonary disease (COPD) — that can also result in reimbursement reductions for 30-day readmissions.(1)  To give you an idea of the number of Medicare patients readmitted to the hospital for COPD alone, the readmission rates for this condition range from approximately 18 to 25 percent.(2)

The current one percent penalty hospitals face for high readmission rates will increase to three percent in 2014. For some hospitals, these penalties will result in the loss of millions of dollars in Medicare reimbursements.

Research shows that when patients are discharged and lack the necessary care and support at home, they are at high risk for readmission. Hospitals are taking this issue seriously and many have developed Transition of Care (TOC) departments and programs to help patients recover post discharge and avoid readmission.

Many hospitals are also partnering with home care agencies to ensure the coordination and continuation of health care for their discharged patients. To help hospitals reduce their readmission rates, home care agencies such as ComForcare Home Care, have developed TOC programs that assess the needs and health goals of recently-discharged patients and provide enhanced care services to meet them. In 2012, the ComForcare TOC program,Patient-Centered Transitions by ComForcare, received a national award from Dorland Health.

If you or a loved one has been recently hospitalized for one of the conditions being tracked by CMS, you may have noticed a more detailed discharge process that involves more health care professionals.

A comprehensive TOC program is one of the most effective methods to reduce the risk of readmission. The program should include the following and be explained to patients and family caregivers at the time of discharge:

1.      A team approach for recovery that includes hospital physicians, nurses and a discharge planner, the patient’s primary physician, specialty physicians, visiting nurses, professional home care provider and family members.

2.      A thorough explanation of all discharge instructions and a copy of the discharge instructions to follow at home.

3.      A comprehensive medication profile that includes easy-to-read and follow dosage instructions.   

4.      Team members using “teach back” methods to help the patient and family members understand and follow the discharge instructions.

5.      Education on the warning signs of the patient’s medical condition(s) and what to do if they occur.

6.      A telephone triage system for patient or family caregiver questions or for immediate assistance if the patient’s condition worsens.  

7.      A recommended schedule of follow-up appointments with the patient’s primary and specialty physicians and assistance with scheduling and transportation to these appointments, when necessary.  

8.      Regular RN home visits to monitor recovery and report results to the patient’s care team.

The additional discharge procedures may seem overwhelming, especially when you or a loved one is eager to leave the hospital and return home, but they are necessary to promote recovery and prevent readmission.

1, 2:        Law360.com, a LexisNexis company, May 6, 2013, “CMS Just Getting Started On Hospital Readmission   Penalties,” Jeff Overley

Bryan J. Romane - Owner

ComForcare Home Care of La Grange

Supporting Independence, Dignity and Quality of Life 

708.261.0080

http://chicagowest.comforcare.com/