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.”