Getting out of the hospital is often just the beginning of the struggle for elderly patients. According to a 2009 study published in the New England Journal of Medicine, about one in five hospitalized Medicare patients find themselves back in the hospital within 30 days.
That cycle costs $17 billion a year. To cut that figure, and more important, to reduce the suffering faced by such patients, Jewish Family and Children’s Service of Greater Mercer County has partnered with Robert Wood Johnson University Hospital Hamilton to launch a new program.
The two-year Mercer Care Transition Program is being funded with a $300,000 grant to RWJ Hamilton from the Robert Wood Johnson Foundation (no relation to the hospital) through its New Jersey Health Initiatives Program.
According to Joyce Schwarz, vice president of quality at RWJ Hamilton and the project director, it will focus on 350 patients who are at least 60 years old and who suffer from congestive heart failure and/or diabetes and at least one other chronic condition, and who have already been hospitalized two or more times.
At the heart of the program will be a transition coach from JFCS who will work with the patients — and their caregivers if needed — to help them manage their own care after discharge.
The agency works with around 1,600 seniors a year in three different programs. Judy Millner, program director of JFCS Secure@Home, will supervise the coach. She said they hope to spare people “the devastating impact rehospitalizations have on quality of life for both patients and caregivers.”
‘Navigate the system’
For each participant, the 30-day intervention will include one hospital visit, one home visit, and three follow-up phone calls. The goal is to help patients keep appointments with physicians, follow doctors’ instructions for follow-up care, and comply with the prescribed medication routine — all strategies that help prevent relapses and re-admission
Millner said the agency has hired a registered nurse who has both hospital and home care experience to serve as the coach. She hopes to begin working with patients on Oct. 1. “It is a close-ended intervention,” Millner emphasized, and the coach will be expected to work with 15 to 17 people at a time.
“The people selected will also have additional vulnerabilities like advanced age, frailty, or low income,” she said, and added, “Finding them isn’t a problem. Unfortunately, it’s not hard to identify people who are unable to manage their own care.”
The MCT program is part of a statewide initiative that includes nine projects funded under the RWJ Foundation’s NJHI 2011: Transitions in Care program. All feature innovative strategies and collaborations designed to address the needs of individuals transitioning to various levels of care after hospitalization.
Millner said that there will be very careful monitoring of the MCT program’s results, first so that it can be fine-tuned, if need be, to ensure it is reaching those who can most benefit from it, and secondly “so that we have real numbers to show, to help improve patient care and hospital procedures.”
Skip Cimino, president and CEO of RWJ Hamilton, said, “Controlling readmission rates is a critical issue for all hospitals as we work to improve the health and well-being of our community. As we move forward with healthcare reform, health plans are less likely to reimburse hospitals for these return visits.”
Schwartz, the program codirector, said, “The goal is to improve the quality of life for our patients and to help them become more engaged in the management of their own healthcare. We believe our patients can learn the skills from the coach that they need to navigate the complex healthcare system we have in this country. Ultimately, less time spent in the hospital is better for the patient and their caregivers.”