When a patient must be readmitted to a hospital, it not only causes distress to the patient, it drives up health care costs. But two new studies suggest that better communication before a patient is discharged and better coordination after his discharge can reduce readmissions.

By one congressional agency’s estimate, readmissions within 30 days cost Medicare $15 billion a year. To tame those costs, the Affordable Care Act includes a program that offers incentives – and penalties – for hospitals to reduce Medicare patient readmissions.

One of the two studies, which appeared in the Archives of Internal Medicine, assessed the real-world effectiveness of a program called Care Transitions Intervention, or CTI, for patients making the move from the hospital to their home. The 30-day program, which had had success in a controlled setting, involves coaching patients in person and over the phone in order to “empower individuals to manage their health and communicate effectively with their providers.”

More than 1,000 Medicare patients at six Rhode Island hospitals were invited to participate in the CTI program; 257 (24.7 percent) accepted. The CTI participants were taught to identify their medical problems; understand their prescription medication and when to take it; recognize whether their condition is worsening and how to reach out for help; and discuss/practice how to schedule a follow-up visit.

This group had a hospital readmission rate of 12.8 percent, compared with the 20 percent readmission rate of those who did not take part in the intervention. 

“In our hands it was a roughly 36 percent reduction in the odds of readmission; that’s pretty good. That’s a very inexpensive intervention for what you get,” says senior author Stefan Gravenstein, MD, a professor of medicine at Brown University Alpert Medical School and the clinical director of Quality Partners of Rhode Island, a Medicare-contracted quality-improvement organization. “The people who are just coming out of the hospital are uniquely at risk of having things happen to them, so they need to know when and how to reach back into the system and get help before it becomes an emergency.”

More than 400 medical centers offer formal transition care, but the rate of readmission within 30 days remains high among people older than age 65. “That percentage of medical [readmissions] is somewhere between 20 and 30 percent, depending on what part of the country you’re in,” Dr. Gravenstein says. “That means you have a on1-in-5 chance of ending up back in the hospital if you’re a Medicare patient. To me that’s a lot.”

Patients being discharged should have the four skills that the CTI program teaches, he adds. “We providers should be teaching patients how to do this in the first place. That should be part of their vocabulary. They should be health literate, and the fact they don’t know means we are failing them in a big way.”

Another study assessed a transition-care program at Baylor Medical Center Garland, in Texas, for heart failure patients aged 65 and older. Of the 140 Medicare patients eligible for the study, 56 (40 percent) elected to participate. They received guidance from specially trained nurses before discharge and at least eight home visits, and their readmission rate was 48 percent lower than the group that didn’t take part.

“The response was impressive,” says lead author Brett D. Stauffer, MD, an internal medicine doctor at Baylor Healthcare System in Dallas and a clinical scholar at the Institute for Health Care Research and Improvement. “As much as we’d like to believe that patients listen to their doctors, the fact is, when you’re in the hospital and getting discharged home, you often are in a state of flux,” he says. Intervention is effective when patients “have someone with medical knowledge interacting with them in their homes, rather than just getting abstract directions at time of discharge.”

An editorial in Archives of Internal Medicine points out that a weakness of both studies was the low participation rate. Dr. Stauffer’s team didn’t study why patients didn’t participate; anecdotally, some said they didn’t want someone from the hospital going to their home.

Still, he believes patients will get accustomed to the practice. “We are so early on in the discovery phase and implementation phase, there is lots of opportunity for people to learn to do this,” he says.

Geoffrey H. Westrich, MD, is co-director of joint replacement research at the Hospital for Special Surgery in New York City, which performed 8,000 knee and hip replacements last year. Though transition programs likely pay off in the long run, he says, the short-term price tag is a challenge.

“We know if you spend more money on it and had nurses contacting patients postoperatively, I think we would drastically lower our re-admission rates. The problem is there are upfront costs, and who will pay for that? With 8,000 knee and hip replacements, we would need to hire several nurses whose whole job would be contacting patients,” Dr. Westrich says. “It’s a good concept, and I fully believe in follow-up and transition care, but I think the cost is always going to be a factor.”