Study Finds That Many Medicare Patients are Rehospitalized,
 Raising Costs

A study published in the April 1st New England Journal of Medicine found that as many of one-fifth of all Medicare patients are readmitted within a month of being discharged and one-third are rehospitalized within three months. Moreover, half the patients who returned to the hospital within 30 days of receiving treatment (other than surgery) did not see a doctor before they went back, leaving many older patients with heart failure or diabetes to cope on their own. Frequently, these patients do not receive clear instructions regarding which medications that they should take or which warning signs to watch for. However, organizations such as Geisinger have proven that active efforts to reduce readmissions can have a big impact. Simple steps such as alerting patients' doctors about the hospitalization, forwarding a brief summary of the patients' discharge plans with 72 hours of discharge, as well as educating the patient before they are hospitalized can all significantly reduce rehospitalization rates. Coaching patients and caregivers about how to better manage their conditions, including when to take medications and how to spot complication warning signs can also reduce the risk of rehospitalization. The authors of this study also suggest changing how hospitals and physicians are paid by rewarding those that help patients stay better is an essential step.

An abstract of this article is available at: http://content.nejm.org/cgi/content/abstract/360/14/1418. Please note that subscription is required for full text access

An earlier, but related New England Journal of Medicine article by Thomas Bodenheimer, in a special issue of the journal devoted to primary care, discusses causes and solutions for poor care coordination. Dr. Bodenheimer cites research showing that the typical Medicare beneficiary sees a median of two primary care physicians and five specialists each year, in addition to receiving a host of diagnostic and pharmacy services. Patients with several chronic conditions often see up to 16 physicians per year. He suggests an "overstressed primary care system," "lack of interoperable computerized records," "dysfunctional financing," and a "lack of integrated systems of care" are the key culprits. Bodenheimer has found that coordination between primary and specialty care is essential for improving care coordination. For example, electronic referral that does not necessary require a patient to see a specialist can help—for example, providing test data to a nephrologist or a digital photo of a patient's skin condition with patient history. He also recommends referral agreements between primary care and specialty care that clearly specify roles and responsibilities of the providers. Additionally, active steps to improve post-discharge care that coordinate hospitalist care with follow-up community care can help, as well as advanced practice nurse-led interventions that may include hospital visits, post-discharge home visits, and phone follow-up calls. He’s also a strong advocates for health coaches who train patients and family members in self-care as a strategy for reducing avoidable health care costs.

Bodenheimer's "teamlet” model is one simple, yet promising approach for improving care coordination in small physician practices where most care is delivered. The teamlet model pairs a physician with a health coach which can be a nurse practitioner, nurse or even a medical assistant for very small practices. The health coach handles care before the visit, during the visit and after the visit, by assisting with paperwork and authorizations, facilitating receipt of tests, and setting-up follow-up appointments. The health coach also uses reminder systems and checklists to make sure that consultation reports are received by the physician and the patient. In addition to steps to redesign primary care, he also suggests new payment models for care coordination. Commenting on the medical home effort, Bodenheimer cites that with 36% of primary care physicians currently working in practices of one or two physicians, it will be difficult for most to meet the criteria for being certified as a medical home, suggesting that "perhaps successful implementation of the medical home vision requires the movement of ambulatory care delivery in the direction of larger, integrated systems organized as multispecialty groups."

1T. Bodenheimer. A sixty three-year old man with multiple cardiovascular risk factors and poor adherence to treatment plans. JAMA. 2007;298:2048-2055.

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