While she was still in the hospital, Emma Musser started worrying about what would happen when she returned home. With this recent health scare, and with her other chronic health problems, she wasn’t sure she could manage on her own.
Musser, 65, found help through Forsyth Medical Center’s transitional care program, Hospital to Home. Thanks to the services of a patient navigator, she got the support she needed.
“She visited me at home, helped me fill out paperwork and checked to see if I needed meals,” Musser says. “She did everything she could think of to help me, and took away a lot of the worry.”
In the Carolinas, the Hospital to Home program in Winston-Salem is one example of a growing focus on what happens to patients when they are transferred from one care setting to another. Experts realize that poor transitions—especially for frail older adults—can push patients back to the hospital, compromise health gains and add to costly bills.
In one recent study, the New England Journal of Medicine reported that nearly 20 percent of Medicare beneficiaries were readmitted within 30 days after leaving the hospital, and 34 percent were readmitted within 90 days. Hospital costs for those readmissions were estimated at more than $17 billion.
With the number of older Americans increasing, health care providers know that establishing effective services and support systems will only become more important. The Patient Protection and Affordable Care Act has added to the urgency, since hospitals with high readmission rates may be penalized by Medicare.
Filling a Need
At The Duke Endowment, several grants have helped to address the needs of an aging and high-risk population. The efforts aim to improve health outcomes for vulnerable patients and reduce unnecessary trips to the hospital.
Trustees approved the first grants in this area in 2008. Carol Woods, a not-for-profit continuing care retirement community in Chapel Hill, came to the Endowment with a plan for building public-private collaboration to improve care transitions for older adults and adults with disabilities. The initiative—now called Community Connections—sought to assess needs, find gaps and coordinate existing resources.
That role included bringing people to the table to build a community-based model of support.
Through Community Connections, the three-year grant made it possible to:
- Expand evidence-based programs, such as PACE (Program of All-inclusive Care for the Elderly).
- Build links with the Department of Health and Human Services, UNC Chapel Hill, Duke University, Piedmont Health Services, Community Care of North Carolina and more than 100 other organizations.
- Bring groups together to develop the Chatham-Orange Community Resource Connections for Aging and Disabilities initiative, designed to streamline access to long-term services.
- Fund an in-home telehealth monitoring pilot for patients with congestive heart failure.
- Support a randomized-controlled trial to study the impact of a telephone follow-up for seniors discharged from the UNC emergency department.
- Support internships and stipends for students in aging services.
After the initial funding, Carol Woods received a two-year grant from the Endowment to expand efforts. So far, Community Connections has helped launch several pilot projects and laid the groundwork for continuing collaboration.
“Here’s a model for improving care transitions, but also for creating community collaboration,” Altman says. “For a while, we were just trying to create an awareness of the importance of this topic. And now many people are engaged and at the table excited about the impact we can make.”
A Quality of Care Issue
Eighty miles away, leaders at Forsyth Medical Center in Winston-Salem, N.C., have been looking at the complex issue from a hospital’s viewpoint. Their effort—Hospital to Home—also received Endowment support in 2008.
“The hospital recognized a gap between when the patient was discharged from the hospital and when community support services were able to start,” says Lynn Watkins, project manager at Forsyth. “There were reasons beyond medical issues that made people more prone to readmissions.”
Using a California model as a starting point, Forsyth hired a social worker to bridge the gap between hospital and community services. Called the patient navigator, the social worker initiates services with an extensive interview in the hospital, and then follows-up with home visits.
Using a social worker helps determine the psycho-social needs of patients, Watkins says. “A social worker can help patients understand that things may be more difficult after they get home than they were before,” she says. “Sometimes it becomes a matter of helping people understand they really do need more support than they think they do.”
Through Hospital to Home, Forsyth contracted with a local company to provide services such as transportation to doctors’ appointments, medication pick up at the pharmacy, grocery shopping, light housekeeping or meal preparation.
The services are free to patients who qualify. The navigator usually makes three home visits and three follow-up phone calls and sees about 200 people a year.
In the first year, Forsyth saw a 53 percent reduction in hospital readmissions among high-risk patients. But Watkins also points out another measure of success: Using the Quality of Life scale, patients involved in the program reported improvement in their mental health, as well as physical health.
“In all the domains, they showed improvement,” she says. “If you provide people the supports they need, obviously they are less stressed, and that can lead to improvements in their physical and mental health. Beyond the drop in readmissions, to me that was one of the very important outcomes that we had.”
According to patient survey responses, overall satisfaction with the program is 4.84 out of 5.
In May 2012, the effort won federal funding through a two-year Medicare program designed to test models of care transitions. Called the Northwest Triad Care Transitions Community Program, the expanded initiative will include a network of community organizations and seven acute care hospitals in three counties.
Also, through a grant from The Duke Endowment, the Hospital to Home model is being replicated at Sisters of Charity Providence Hospitals in Columbia, S.C.
For a growing number of patients, the extra effort could mean the difference between a full recovery—and a return to the hospital for more care. For Emma Musser in Winston-Salem, it “meant all the difference in the world.”
“I would have been in bad shape when I got home,” she says. “I’m much better off than I would have been.”
Lin B. Hollowell III
Director of Health Care