After a recent three-week hospital stay for surgery and a bout of pneumonia, Don Cottrill wanted to stay in his Munroe Falls home to recover.
A program run by Summa Care insurance in partnership with the Greater Akron-Canton Area Agency on Aging is helping ensure his journey back to health doesn’t include a trip back to the hospital.
Cottrill, 75, is among more than 350 older residents in the area who have received extra support through what is called Bridge to Home.
The initiative provides free health coaching for SummaCare Medicare managed-care enrollees who are hospitalized with five targeted health problems: atrial fibrillation, chronic obstructive pulmonary disease, congestive heart failure, gastrointestinal bleeding and pneumonia.
Through the program, SummaCare has been using nurse case managers from Summa or the agency on aging during the past year to educate patients before and after discharge.
The goal is to prevent a return to the hospital for patients with these conditions, which tend to have the highest risk for rehospitalization within 30 days, said Dr. Nancy A. Istenes, Summa’s medical director for long-term and transitional care.
“If you ask any senior, ‘Where would you rather be, home or in the hospital?’ they’re going to say, ‘Home,’ ” Istenes said. “It’s really a marker of health in these patients, not just a cost savings for the hospital.”
Hospitals are under increasing pressure to reduce the number of patients who come back within 30 days after discharge. Beginning in October 2012, the federal Medicare program can withhold a portion of inpatient Medicare payments to hospitals that have a “higher- than-expected” readmission rate for heart failure, heart attack and pneumonia patients.
The 30-day readmission rate among Ohio hospitals is 19.8 percent, compared with 17.5 percent nationwide, according to the Commonweath Fund, a nonprofit group that promotes medical system improvements.
For Cottrill, a Bridge to Home case manager is providing follow-up calls and visits to review his medications and determine whether he needs help, such as an aide to help with bathing.
The Area Agency on Aging is working with the Akron Regional Hospital Association to launch a similar initiative for more patients with the targeted conditions at 11 hospitals throughout the Akron-Canton area.
The partners have submitted a proposal for a five-year, $9 million federal grant that would allow the agency on aging to provide coaching to all Medicare patients hospitalized at participating facilities with heart attacks, heart failure or pneumonia. A decision is expected by Sept. 15.
If it is approved, the Area Agency on Aging health coaches “will make sure that the patient has their medication and it’s filled so it’s available to them when they go home,” said hospital association President and Chief Executive Marianne Lorini. “Sometimes patients go home and they don’t have a ride to get their medicines. The other thing they need is follow-up with their primary-care physician. Through this coach experience, it will give us a lot of information we don’t currently have.”
Participating hospitals include Affinity Medical Center in Massillon; Aultman Hospital and Mercy Medical Center in Canton; Summa Akron City and St. Thomas and Akron General Medical Center in Akron; Summa Barberton Hospital; Summa Western Reserve Hospital in Cuyahoga Falls; Lodi Community Hospital; Summa Wadsworth-Rittman Hospital; and Robinson Memorial Hospital in Ravenna.
Case managers from the Area Agency on Aging already have been working within area hospitals on initiatives to help patients make a smooth transition to their homes or a community setting, said Joseph L. Ruby, the agency’s president and chief executive.
About a year ago, the agency conducted a program at Western Reserve and Robinson Memorial that provided a coach for patients with heart disease, stroke, cancer, diabetes and chronic obstructive pulmonary disease.
Through free home visits and follow-up phone calls, the nurses reduced the readmission rates for participating patients to less than 2 percent, Ruby said. Typically, about one in five patients with those conditions ends up back in the hospital within 30 days.
Hospitals don’t get paid by the federal Medicare program for providing health coaching, Istenes said. But the hope is the federal government will start reimbursing for these initiatives if they are proven effective.
“If those nursing visits prevent a hospitalization,” she said, “the cost difference is enormous.”
Cheryl Powell can be reached at 330-996-3902 or firstname.lastname@example.org