Originally published February 6, 2013 at 11:05 a.m., updated February 6, 2013 at 3:18 p.m.
Don Ryan, patient who went through the Transitions program
Dr. Nick Yphantides, Chief Medical Officer, San Diego County Health and Human Services Agency
Emily Awkerman, Assistant Director of Case Management Sharp Healthcare
After a health crisis, patients are usually released from the hospital with a handful of papers explaining how they should take care of themselves when then get home. But when those patients are elderly and suffering from complex medical conditions, they often have to be readmitted to the hospital. In fact, the government says one in five Medicare patients are readmitted within a month of release.
In an effort to save money and help patients, many hospitals are turning to community-based health support programs. In San Diego, that's the Care Transitions program, which was just selected by Medicare to expand its services to thousands of patients across the county.
Under the Affordable Care Act, Palomar Health, Scripps Health, Sharp HealthCare and the University of California, San Diego Health System will receive patient Medicare reimbursements over the next two years to expand the program to 13 hospitals.
Care Transitions was piloted in 2009 at Sharp Healthcare. That's where 85-year old Don Ryan learned about the program after being admitted to Sharp Memorial with heart complications.
Ryan says the program taught him how to take control of his own health.
County health officials say Care Transitions tracks patients for 30 days after they are discharged with a combination of in-home visits and phone calls. They say the program provides patients with skills such as, medication management, maintaining a personal health record and recognizing “red flags” in their health to know when to follow up with their doctor. The goals of the program include reducing hospital readmissions for Medicare patients by 20% and documenting measurable savings to the Medicare program.
Officials say the pilot program in the county, which involved 88 patients, showed a reduction in hospital readmissions by more than half and saved taxpayers millions of dollars, by preventing claims to Medicare.
Hospitals across the country are under increased pressure to lower readmission rates. Under the Affordable Care Act, the federal government is now fining hospitals that have too many readmissions. 8 local hospitals were hit with readmission penalties late last year.