Here’s a number that tells you a lot about what’s wrong with the American health care system: When older patients get discharged from a hospital, 1 out of 5 of them will come right back within a month. Medicare pays $17 billion a year on these hospital readmissions. And in many cases, coming back should have been avoidable.

Mary Naylor is trying to change that. She started the Transitional Care Model at the University of Pennsylvania Health Care System in Philadelphia. A nurse with advanced training in geriatrics is assigned to an elderly patient while he is in the hospital and then follows the patient, with frequent visits and contact, over two or three months to help him manage his own care.

“Every time an older adult is hospitalized, it generally results in changes in their plan of care,” says Naylor. Some of the instructions from a doctor can be hard to follow, like new prescriptions. “So they would go home and 24 hours after discharge have a set of prescriptions, drugs already in their cabinet and wonder, ‘Should I be taking these plus these?'”

Naylor says it’s often in these first 48 hours that things go wrong.

That’s why the transitional care nurse, usually a nurse practitioner, arrives at a patient’s home within the first 24 to 48 hours after discharge. The nurse then makes weekly home visits, even multiple visits in a day if necessary. The nurse will even go with a patient to see his or her primary care doctor for the first time after leaving the hospital.

“It’s the same nurse who begins to work with the patient in the hospital,” Naylor says. “They become the point person, they become a broker of care for these individuals over time. And they only leave them when they think that Mr. Smith or Mrs. Jones is no longer at risk for a poor outcome.”

Health Care Translator

“Before this, when I came out of the hospital you go, ‘Yeah? What do I do now?’ It was, ‘See ya,'” says Ken Rogers, 80, a retired supervisor at a printing company.

Rogers went to the hospital in June with chest pains. Doctors were unsure of the cause and kept him in the hospital for a week. Jessica MacLeod, a nurse, visited Rogers every day at the hospital. When he was discharged, she was at his house within 24 hours and then continued to make home visits.

On a recent afternoon, MacLeod, who will finish her program to become a nurse practitioner next month, drives up in her worn Toyota Corolla and visits Rogers and his wife, Peg, in the sunroom off their brick house. She does a quick examination, but she isn’t rushed and ends up spending an hour with the couple.

She reviews the instructions Rogers got from his cardiologist and takes the couple’s questions about the medication he has just started to treat his atrial fibrillation and what foods he needs to avoid as a result.

“Mr. and Mrs. Rogers, I would consider very smart and savvy people – and assertive,” MacLeod says. “And even having those skills, health care is complex and we have a health care system that is increasingly complicated. And, you know, if you’ve ever been to the doctor’s office yourself, you are hearing words for the first time and they’re maybe said once and it’s hard to get a word in edgewise sometimes and say, ‘Wait, what is atrial fibrillation, doc?’ You know, what does that mean? So part of my job is a translator, really, and I translate the language of health care to a lay person’s language.”

Offering Objectivity

On another recent day, Brian Bixby, a nurse practitioner, pushes 84-year-old Lucy Brisbon in her wheelchair as she goes to visit her doctor. Brisbon is accompanied by her daughter, Beverly Martin, 68, who lives nearby and spends most of the day and night looking after her mother.

Bixby is not only an advocate for the patient, but also for the family. Before the doctor’s visit, he helps the daughter and mother figure out the most important things they want to bring up with the doctor. The doctor’s visit may be short, he explains. He helps them focus their questions to get the most out of the visit.

Still, sometimes doctors resent it when a nurse practitioner like Bixby shows up with a patient. And sometimes the doctor sends the nurse practitioner to sit in the waiting room. But most doctors are like Lesley Carson, Brisbon’s doctor at the University of Pennsylvania Health System.

Carson, a geriatrician, says the transitional care nurse can help her understand things about what a patient needs – things that aren’t always obvious in a doctor’s office.

“For me, it’s like having a very objective person in the home who can give me a lot of the information I can use and who knows how to interpret the information,” she says. “And then we can work together to figure out what to do.”

Cutting Readmission Rates

It’s not cheap to provide all this personal attention for a patient. But Naylor’s studies show the program saves about $5,000 a year for each Medicare patient – largely by keeping them from going back into the hospital.

But Medicare doesn’t pay for the nurse practitioners. And hospitals make the most money when people go into the hospital – not when they’re kept out.

Dr. Stephen Jencks is a researcher and former Medicare official who’s studied the issue. He says it’s time to change the health care system – and start paying upfront to coordinate care.

“We are not in a business where we should have to be accepting this choice that we’re either going to have to cut the care we give or we’re gong to have to accept higher bills,” he says. “There’s a third way of doing it, which is: redesigning the care where we do the things people want that are effective and which cost less than doing it wrong.”

It was Jencks’ study – published earlier this year in The New England Journal of Medicine – that came up with some stunning numbers: 1 out of 5 Medicare patients go back into the hospital in a month – at a cost of about $17 billion a year. Jencks thinks the readmission rate easily could be cut by 15 percent, and with harder work, maybe even in half.

“Almost anybody can see that if you can keep the patient healthy, the patient is better off and Medicare is better off and you’re delivering the kind of care most people would want to have: Win, win, win,” he says.

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