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It was no secret to Karla Hall, a nurse trained in case management, that older patients released from the hospital often boomeranged right back in.

In Bellingham, where Hall worked, as in most places, gaps in communication between the hospital and caregivers in the community engulfed and confused even the most attentive patients.

Should they take the hospital medications and the ones they took before?

If they had heart failure, did they understand why they were supposed to weigh themselves every day — and could they actually see the scale?

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Did they remember they’d been instructed to make a doctor’s appointment right away, or get lab work?

Did their doctor even know their patient had been in the hospital?

Hospital readmissions, often hard on patients and their families, remain one of Medicare’s most vexing and expensive problems — costing the government more than $17 billion a year, according to the Centers for Medicare & Medicaid Services. Last fall, Medicare began sharing the pain, levying financial penalties such as reduced reimbursements to hospitals when too many recently released patients return.

Along with penalties, the government has funded research to improve the transition.

Whatcom County, with Hall’s help, was one of the stars in a national demonstration project in 14 communities around the country aimed at slowing the revolving door that brings as many as 1 in 5 Medicare patients back to the hospital within 30 days.

The results, released in a recent edition of the Journal of the American Medical Association, found that a systematic effort to improve coordination and communication between hospitals and a wide swath of next-in-line caregivers — family members, primary-care doctors, nursing homes, rehab centers and others — made this often-dangerous transition period significantly safer.

Similar interventions are being rolled out in 400 communities around the country, including Pierce County, an ongoing project in Whatcom County and several others in Washington state, many funded through the federal Affordable Care Act (ACA).

In the Pierce County program, which began in July, hospitals, community agencies and a nursing school joined forces, incorporating some elements from Whatcom County and adding other, more hospital-focused innovations.

For asthma patient Wayne McPherson, 72, hospitalized at MultiCare Good Samaritan Hospital in Puyallup, staying out of the hospital is a worthy goal. There, Sarah Jemley, a nurse “care partner,” worked with him, going over medications and a post-hospital care plan.

At first, McPherson said, he resisted help. But recently, during his third hospitalization in a month, thinking about all the medications he and his wife take and how easy it might be to get mixed up, he reconsidered. “I said, you know, I could use a nurse coming in and making sure I’m doing the right thing.”

The demonstration project spotlighted some potential problems, such as increased emergency-room visits. Still, nearly every community reduced the number of Medicare patients readmitted within 30 days; overall, those readmissions fell by an average of nearly 6 percent.

Such a reduction would translate into a net savings of about $3 million for a hypothetical community of about 50,000 Medicare patients, said Dr. Jane Brock, lead study author and chief medical officer for the Colorado Foundation for Medical Care, in a media briefing.

“This was all fueled by people being very concerned with how patients and their families were being bounced around in the system,” noted co-author Dr. Joann Lynn, director of the Altarum Institute Center for Elder Care and Advanced Illness in Washington, D.C.

Developed programs

Each community had its own formula, but most, like Whatcom, concentrated on certain interventions: managing medications; improving discharge instructions; and helping patients create health records, get follow-up care and recognize “red flag” symptoms.

For the project in Whatcom County, Hall helped train community members, retired nurses and church and tribal clinic volunteers to become “transition coaches,” visiting patients at Bellingham’s PeaceHealth St. Joseph Medical Center and at home to help navigate the confusing period.,

Coaches even role-played with patients, helping them learn key words to get a doctor’s appointment quickly and aided them in translating discharge instructions.

“When patients are being prepared for discharge, in the last couple of hours all the information they need to succeed at home gets thrown at them at once,” Hall noted. “It’s overwhelming.”

At home, patients toss the instructions somewhere, not realizing they’re supposed to get lab work or appointments right away, she said. If they get medications by mail, they may have none to tide them over.

“That’s one of the things the coach asks: ‘How do you get your medications?’ ” she said. “There’s not a clear mechanism to make that happen in the hospital.”

Whatcom started with the lowest rate of readmissions in the group. That became part of a “let’s see how low we can go” pitch to Medicare from Qualis Health, the Medicare Quality Improvement Organization (QIO) for Washington and Idaho. Study grants paid QIOs, chartered by Medicare to improve care and lower costs, to convene community players and offer expertise.

In Whatcom County, Qualis gathered representatives from Bellingham’s PeaceHealth St. Joseph Hospital, physician groups, clinics, senior centers, nursing homes, drugstores, home-health agenciesand the Northwest Regional Council’s Area Agency on Aging, now providing coaching for the ongoing project, to brainstorm.

In the study, Whatcom came in with lowest readmission rate, a result of a “crumbling of walls,” said Chris Phillips, spokesman for PeaceHealth St. Joseph Medical Center— walls most patients don’t know exist.

“They assume that doctors and nurses inside the hospital communicate with the doctors and nurses inside clinics in the community,” he said. “And they’re somewhat surprised to find they don’t.”

Medicare goals

Reducing expensive hospital readmissions has long been a goal for Medicare. Now, through the ACA, the federal government is paying for coaching, care coordination and other interventions in communities such as Tacoma and Bellingham, betting that financially, it will make sense.

In a study of more than 3 million Medicare patients admitted to hospitals from 2007 through 2009 with heart failure, heart attack or pneumonia, between 18 and 25 percent, depending on diagnosis, returned within 30 days, most within 15 days.

Over the last few years, none-too-subtle hints from Medicare have morphed into a carrot- and-stick approach.

This demonstration project, which began in 2008, tracking results in 2009 and 2010, was a carrot.

In the old days, said Dr. Terry Rogers, CEO of Seattle’s Foundation for Health Care Quality, hospitals had no incentive to keep patients from returning. With reimbursement penalties and increasingly common “warranty pricing” — one price for a surgery or treatment and subsequent care — hospitals have become keenly interested in paring readmissions, he noted.

Now, some people worry that hospitals may turn patients away.

One elderly patient in Eastern Washington had that experience, her son said.

The hospital discharged her just a few days after multiple-bypass heart surgery — a miraculous procedure by excellent doctors, the son said — assuring her it had arranged for care at a nearby rehab facility.

But she was refused admission because of a miscommunication about her insurance, said her son, who asked that his mother not be identified.

In the bitter cold, his elderly father drove his mother around town, trying in vain to find another facility, finally returning to the hospital, which would not readmit her, the son said. And so “she went home — 60 miles away, to a very small town, with my exhausted and ill 78-year-old father driving.”

In some cases, the demonstration project found, as hospitals focused on reducing readmissions, emergency-department visits increased.

And some researchers say academic-medical centers, where patients are likely to have more complex problems, and “safety-net” hospitals that care for more low-income patients, will be hit hardest by penalties.

But Dr. Harlan Krumholz, director of the Center for Outcomes Research & Evaluation at Yale-New Haven Hospital and author of a commentary on the demonstration project, argued that patients leaving any hospital are in a dangerous period of “generalized risk” and communities must learn to think more holistically to support them while they recover.

Carol M. Ostrom:, 206-464-2249, or at Twitter @costrom

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