Hospital's goal: Reduce readmissions, lower costs

Over a period of 12 months in 2012 and 2013, Brooke Laine's father, Ed Laine, was hospitalized twice with pneumonia.

Each time he came home from Barton Memorial Hospital in South Lake Tahoe, Calif., Brooke tried her best to help take care of her father, but both struggled. Brooke worried about doing the right things and managing her father's mediations. Ed, who is 82, also was worried about getting his medications right.

After the second hospitalization, the Laines found help through a new program provided by the hospital, called Transitions in Care. The program provides nurses to help with care and recovery in the home after a hospitalization. The goal is to reduce costly readmissions to the hospital.

One of the primary goals of the nation's new Affordable Care Act is to improve health care quality and use money more wisely. Hospital readmissions are expensive and in many cases experts believe they are preventable with better primary care. Under the new payment system put in place by the new health law, readmissions are one of the measures that will be tracked and tied to payments. Hospitals will face financial penalties for excessive readmissions of Medicare patients with certain illnesses, including pneumonia, heart attack and heart failure.

Penalties can be as high as 3 percent of hospitals' billings by fiscal year 2015. This is a considerable amount for rural hospitals already working on small margins and facing decreases in traditional Medicare payments under the new law. Barton Memorial is a small 62-bed hospital in a community of 21,000 people.

Under the Transitions in Care program, four registered nurses have been trained as health coaches. When a person is discharged from the hospital, a health coach makes a home visit to review the patient's case and care, including background on the illness and medications, and to answer any questions. The health coach also helps to arrange any follow-up visits with a primary care provider or specialists, and checks back by telephone on day 2, 4, 7, 14 and 30 after discharge.

Monica Sciuto, director of public relations and marketing for the hospital, said the Transitions in Care program is offered at no cost to patients. The hospital had to add more staff but believed the investment would prevent future Medicare penalties and improve care.

When Ed Laine came home the second time, a nurse health coach visited to explain his medications.

"That information was very empowering," Brooke said. "I felt when I went home with my dad on this particular occasion that I knew exactly what he needed. I could make decisions, and I could be that extra set of ears because it is a lot for the patient to take in."

Ed Laine said the home visit made him feel more at ease with his medications. Brooke was there to remind him of medication instructions he forgot. He was not readmitted to the hospital while in the Transitions in Care program.

"Coaching patients to successfully manage their chronic disease, to have quality of life and stay out of the hospital is the hallmark principle of this program," said Mary Bittner, director of nursing at Barton. "It is also about the relationship built between the nurse coach, the patient and their caregivers."