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Written by: John Wolf on Monday, May 13, 2013 Posted in:

Andrew Osterman knows he’s lucky.  He remembers shoveling the snow in his driveway and then waking up in the hospital.  Like many others, Andrew successfully survived a potentially fatal heart attack.  Though grateful to be alive, Andrew and his wife, Mary, are now finding out that getting back to their normal lives is proving to be a real challenge.  Prior to what the Oysterman’s refer to as “the incident,” they considered themselves fairly healthy, visited their family physician only for annual check-ups, and worked on fulfilling their dream of visiting every state in the union.  Instead of planning their next trip, their days are now spent trying to understand and manage their new reality.  Understanding the reason, dose, frequency, and side effects of each of the five new medications Andrew has to take is a bewildering maze of medical jargon and chemical names.  The earliest appointment his cardiologist has is three months from now, yet when in the hospital, the doctor told Andrew he wanted to see him within two weeks of his release.  And when Andrew and Mary saw their family physician, he was completely unaware of Andrew’s admission, treatment, or new medications.  The Osterman’s are understandably overwhelmed – they are smart, sensible people who have been self-sufficient for their entire lives; so how did they get to this point?

Andrew and Mary are part of a much larger pattern identified by the Centers for Medicare and Medicaid Services and others – a hospital discharge than leads to a readmission that could have been prevented.  In fact, one in five (20 percent!) Medicare patients is readmitted within 30 days of hospital discharge at a cost of $26 billion annually.  The underlying issue faced by many patients and their families is the sudden and abrupt need to become quasi-medical experts, understanding and managing a multitude of details in an area they have little to no expertise and/or experience.  The good news is that with a small investment of time and money, many of these readmissions can be avoided and patients become enable to act as their own health advocates.  Care transitions programs come in a variety of models and include the widely used Coleman, Naylor, Bridge, Project RED, and Project BOOST models.  All models share the common goal of coaching and guiding the patient and their family members to be able to successfully manage many aspects of their healthcare – medications, warning signs and symptoms, and physician and caregiver communication.  Program length can vary (typically 30-90 days), but the components – in-person visits, calls, and, in some cases, facilitation of support services such as transportation to an appointment – are simple.  Coaches work with patients to help them gain the skills and confidence they need, providing tools such as an individual health records and templates to record questions for their physicians, and ways to manage their medications.

Too good to be true?  Not according two major studies [1],[2] that have shown a four to one return on investment (for those of us that were never good at math, Medicare saves a whopping $4 million in hospital readmission costs for every $1 million it spends on community-based care transitions!) and that readmission rates are dropping.  The initial five year investment of $500 million (as allocated by the 2010 Affordable Care Act) represents a potential savings of $2 billion in hospital readmission costs.  Moreover, patients and their families are happier and are returning to their normal lives and routines.

So here’s the catch…even with a clearly proven record of clinical and fiscal success, Congress is proposing cut $200 million from the program – that translates to a loss of $800 million in savings over the same time period.  This doesn’t make sense from any angle.

So even if you’ve never done it before, pick up the phone, send a letter, compose an email, or tweet your representatives know that this is a program worth saving! You can find contact information for your representatives here.