In America, there’s a big problem with people getting discharged from hospitals, and then having to come back because something went wrong. Medicare, the government health program for people over age 65, sees about 20 percent of its patients being re-admitted within a month of being discharged. And that costs money.
In Montana, Missoula was the first to join a national program to help keep people from bouncing back into the hospital. People like Bob and Lorie Christensen. They agreed to participate in the program after Bob was discharged from St. Patrick Hospital late last year. Lorie said it really helped.
“Boy I’ll tell you what, dear,” said Lorie, “it’s too bad that elderly people are ignorant like we were as far as the Aging Services go because people don’t realize how much they really can help, and do help.”
Bob was hospitalized for nearly a month for a heart condition. Before he left, St. Pat’s connected him with Missoula Aging Services. They sent a “care coach” to help Bob sort and understand all the new medications he was on. For the next 30 days, Bob would get phone calls from his coach, checking on his general well-being, or just to say hello. Bob says he appreciated that more than anything else.
“I mean, they keep in touch with me all the time, St. Pats did,” said Bob Christensen. “Aging Services they helped me with that.”
The idea is that if Bob and Lorie can be independent at home, the likelihood of Bob needing to be readmitted to the hospital would seriously decrease, saving some major money. Nationally, readmissions cost Medicare more than $26 billion a year, the agency says.
Bob’s care coach is Shelli Fortune. She says at first, it can be hard for people to understand that her job is to help them have a good recovery at home, at no cost to them.
“In a lot of cases I maybe haven't met them in the hospital so I'm just doing a cold call,” said Fortune. “So I’m showing up without knowing who these people are or how they are going to react to a stranger being in their house.”
But a lot of people eventually say yes. And, hospital readmissions among the elderly in Missoula have gone down recently, by one-point-four-percent. The program’s director, Bernie O' Connor, says it’s a pretty important number since they’re the only nonprofit in Montana running a Medicare program aimed specifically at the readmission problem.
O’Connor has been with the Transitions Program since its first client in March of 2013.
“Since then we’ve added another care coach,” said O’Connor. “We’ve expanded our program statewide really and we’ve dropped the readmission rates.”
If a client goes more than 90 days after discharge without being readmitted, then they are considered a success story.
With new care coaches the program could see more than 125 clients per month, which means more stories like Lorie and Bob Christensens’.
“You gotta take care of yourself you know, you can’t be stupid,” said Bob. “We’ve lost of lot of friends just because they’re stupid, they didn’t help themselves, and now they’re dead and I’m not.”
The Christensens think more people should know about getting care coaches to help them recover after a hospital stay, and so do hospitals. That’s because, under the Affordable Care Act, the federal government has started financially penalizing hospitals with high readmission rates for their Medicare patients. This year, five Montana hospitals got penalties, St. Patrick’s was not among them.
