A new group of coaches is coming to the Atlanta area, but their work won’t focus on athletics. Starting next year, hundreds of Atlanta-area... Coaches to help discharged patients stay out of hospital

Gwinnett Medical Center is one of six metro Atlanta hospitals that will participate in the coaching project for Medicare patients who have recently been discharged.

A new group of coaches is coming to the Atlanta area, but their work won’t focus on athletics.

Starting next year, hundreds of Atlanta-area Medicare patients will each be assigned a ‘‘coach’’ to help guide their transition from hospital care to living at home. The goal is to prevent these patients from being readmitted to the hospital within 30 days after they are discharged.

The Atlanta Regional Commission (ARC) and six metro hospitals are participating in the coaching project, called the Community-Based Care Transitions Program. The ARC was selected by federal officials as one of the seven community organizations in the country to take part in the project, and it will receive funds for the coaches as well as providing other services for patients.

“This is a tremendous opportunity, combining the need to cut the cost of care with improving the quality of care,’’ says Cathie Berger, director of the Area Agency on Aging at the ARC.

Coaches will first meet with the Medicare patients in the hospital, and then make home visits after discharge, checking for problems with medication or other issues. If necessary, a coach can arrange for a patient to receive meals and transportation to a doctor’s appointment. Medicare will pay the ARC for these services, Berger says.

The transitions program was created by the federal health reform law of 2010, and is part of the national Partnership for Patients, which aims to reduce hospital readmissions by 20 percent.

A readmission is not only a bad sign for a patient, but it drives up the cost of medical care. And the high number of readmissions nationwide adds up to a huge expense.

While many return trips to the hospital within 30 days are unavoidable, it’s estimated that the avoidable readmissions cost Medicare $17 billion a year.

Georgia is in the middle of the pack among states in hospital readmission figures, Berger says.

Focusing on three types of patients

Despite increased attention to the issue, a Dartmouth Atlas study of Medicare patients found that readmission rates for hospitalizations that didn’t require surgery rose from 15.9 percent in 2004 to 16.1 percent in 2009.

“Lack of coordinated care between hospitals and caretakers such as nursing homes or home health providers can sometimes result in medical complications and costly, potentially avoidable return trips to the hospitals,’’ said Dr. Donald Berwick, former administrator of the Centers for Medicare and Medicaid Services.

The six hospitals participating in the Atlanta Care Transitions Program are Emory University Hospital Midtown, Gwinnett Medical Center, Piedmont Hospital, Southern Regional Medical Center, WellStar Cobb Hospital and WellStar Kennestone Hospital.

Nancy Morrison of Sixty Plus, a Piedmont program for older adults and their families, says the Buckhead hospital has focused on post-discharge care of patients for several years. The new program, she says, “will give us a trained, professional coach who will be able to oversee the discharge and will see them in the home.’’

“We’re not reinventing the wheel,’’ she says of the project. “We’re just driving it.’’

The two-year Care Transitions program (if successful, it can be extended  longer) will focus on readmissions from three diagnoses: heart failure, heart attack and pneumonia.

Of the six metro Atlanta hospitals in the program, all performed at the U.S. average for readmissions of such patients except for Piedmont, which was better than the national mark for heart attack and heart failure patients, and WellStar Kennestone, which was worse than the national average on pneumonia patients, according to the Hospital Compare website run by CMS.

There’s a major added incentive for hospitals to perform better in preventing readmissions: Hospitals with high readmission rates will lose up to 1 percent of the Medicare billings starting next October. Those penalties will rise in following years.

Plenty of blame to go around

Reasons for readmission can start at the hospital level, with a discharge that’s done too soon or with inadequate planning, says Dr. Alan Bier, chief medical officer at Gwinnett Medical Center.

Medication problems are another frequent cause of readmission. A patient may not understand how to take a new medication, or may not have had the drug assessed for possible interactions with his or her other prescriptions.

Patients sometimes are at fault. Many don’t see a physician after they are discharged. “Often, people don’t follow up with medical appointments,’’ Berger says. The transitions program will aim ‘‘to get the patient involved in their own health care.’’

Coaching patients properly requires considerable effort, experts say. Just making phone calls to check on discharged patients is not enough to achieve real results, Bier says.

He adds that it’s important for patients to understand the red flags associated with their specific conditions, such as weight gain in heart failure patients. The coaches ‘‘can speak in a lay language’’ that the patients understand, Bier says.

Studies have shown that the help of coaches can reduce return trips to the hospital. The Archives of Internal Medicine published a Rhode Island study recently showing that in cases where a coach performed a hospital visit, a home visit and follow-up phone calls with a patient, the readmission rate was lowered to 12.8 percent, versus a 20 percent rate for a group that did not participate.

Hospitals involved say the coaching program can help them reduce readmissions. “It’s a win-win for both our patients and our organization,’’ says Amanda Bartlett, a spokeswoman for Southern Regional in Riverdale.

The Area Agency on Aging in the Akron/Canton area of Ohio has used transition coaches in a demonstration project as well as with a Medicare Advantage health plan.

The agency is also one of the seven organizations that will launch the program. The coaches are nurses or social workers who receive special training before they begin, said Gary Cook of the Akron/Canton agency.

“We see [discharged patients] in their home, hopefully within 72 hours,’’ Cook says.

“This is a true business solution to reduce Medicare costs,’’ he says.


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Andy Miller

Andy Miller is editor and CEO of Georgia Health News

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