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    Two Alton area hospitals are among those now using a proactive approach to one of the costliest problems in medicine — the potentially preventable readmission of at-risk patients who have had recent hospital stays.
    Working in conjunction with a local senior citizens center, Alton Memorial and OSF Saint Anthony’s Health Center are participating in Care Transitions, a national program in which “health coaches” assist patients, 60 years and older, as they are being discharged in order for them to transition successfully back to their homes by giving them the supports and services they need.
    The program was adapted locally in concert with Senior Services Plus, which is based in Alton and has five locations in the metropolitan area.
    During a four-week program, patients who might not otherwise have the supports they need receive specific support from a Care Transitions coach in order to learn self-management skills to ensure their needs are met during the transition from hospital to home.
    Patients who receive the coaching are said to be significantly less likely to be readmitted and more likely to meet goals dealing with recovery, which is especially important given the number of hospitals that are being fined by Medicare over readmissions that cost the government program billions of dollars each year. In its latest round of fines, its third annual, announced in October, Medicare said nearly 18 percent of its hospitalized patients were readmitted within a month. That meant roughly 2 million patients, costing an estimated $26 billion — $17 billion of which represented potentially avoidable cases.
    Medicare has been gradually increasing the fine against hospitals in the three years fines have been levied — soon it will be up to 3 percent of a patient’s subsidized stay.
    The Illinois Department of Healthcare and Family Services is also cracking down. The agency announced in early September that it will begin collecting $16.3 million in penalties from 82 Illinois hospitals in an effort to lower the number of potentially preventable readmissions and keep patients healthier.
    “Care Transitions is a fantastic program that not only saves money for the hospitals but helps to establish a safety net of resources and supports for seniors to ensure long-term health and wellness success,” said Devon Neal, the community based services director at Senior Services Plus. “To adequately address the wave of senior issues coming our way, we as a community need to focus on the key areas of health and wellness, housing, transportation and financial supports.”
    Neal said the program came about after Medicare — three years ago — started penalizing hospitals over patients readmitted within a 30-day time window, especially if the reasons were considered avoidable.
    The penalties are based on cases involving five specific diagnoses — chronic obstructive pulmonary disease, pneumonia, chronic heart failure, hip and knee ailments and heart attack.
    Care Transitions is a nationally recognized program. Senior Services Plus coaches were trained using the Dr. Eric Coleman model of Care Transitions from the University of Colorado School of Medicine.
    Nancy Magurany and Krista Camp, two social workers at Alton Memorial Hospital, are the keys to the program there. They work directly with Stacey Noble-Loveland, a certified Care Transitions intervention coach at Senior Services Plus.
    “There are four ‘pillars,’ (in the transition to home),” Noble-Loveland said. “Making sure patients are using their meds; making sure they have their follow-up appointments; talking to them about red flags (warning signs regarding health); and a personal health record — a place to put all their medical stuff in one place, so it’s easy access for them.”
    The process begins in the hospital and the patients are identified by the social workers as patients at risk for readmission or someone they feel could benefit from having additional supports in the home.
    Magurany covers the medical telemetry floor and has elderly patients with whom she does a psycho-social screening.
    “I interview the patient’s first who have been readmitted or after speaking with them feel they need additional help and then refer them to Stacey. I’m looking for the support they have at home. If they don’t have a support system, they’re a good person for Stacey’s program,” Magurany said.
    Camp and Magurany said patients are sometimes more consumed with everyday life than they are their own health, once they’ve returned home. They recounted how one recent patient needed glasses, while another one was fixated on a broken door. Each of them was eventually helped with the non-health problems so they could concentrate on their recoveries.
    Noble-Loveland added: “There are a lot of things that happen once folks go home, and we can help get them connected to supports and services.”
    Many patients aren’t entirely truthful about their situations at home, which makes the follow-up care all the more important.
    “Sometimes the story they tell us at the hospital is different than when they get home,” Noble-Loveland said. “Some people are too proud to be honest about their circumstances.”
    Elderly people will often “make up every excuse” to prevent unnecessary attention to their plights, which includes the fact that they don’t have family around to care for them.
    Economic disadvantage also factors in.
    “Especially in this area, there are so many people at or below the poverty level and they don’t have those supports. The Care Transitions coach can follow them into the home. They’re social workers and gerontologists, and they come from a different perspective,” said Noble-Loveland.
    Noble-Loveland splits her time between cases involving the two Alton hospitals. Another Care Transition coach from Senior Services Plus works with Memorial Hospital in Belleville.
    The Alton program evolved after Centers for Medicare and Medicaid began penalizing hospitals.
    “Our program started by watching those trends. We’ve come up with a unique approach, connecting the hospital knowledge with the community supports,” Neal said.
    Meetings first began about two years ago and involved a number of hospital and community leaders, in hopes that the Care Transitions project could build resources.
    “We kind of came up with a memorandum of understanding,” Neal said. “It’s at no cost to the hospitals and no cost to the patients, at the moment.”
    The future of the Alton-based program may be determined by the success of an unrelated pilot program started in 2011 and being tested nationwide by the Centers for Medicare and Medicaid. That program, called the CCTP Pilot Program (Community-based Care Transitions), is also exploring ways to save money by preventing hospital readmissions. It is due to wrap up in 2015. Depending on the pilot program’s success, the Alton version of Care Transitions may eventually fall under the umbrella of a larger managed-care plan.
    The state Department of Healthcare and Family Services policy regarding potentially preventable readmissions requires hospitals to review their discharge planning and post-discharge care to ensure patients aren’t being discharged too quickly, while still sick or with poor follow-up care. Hospitals with unacceptable PPR rates face penalties from the state that equal the cost of the excess readmissions.
    As of September, the department had recovered $5.6 million in penalties through hospital payment reductions.
    “This was negotiated more than a year ago, and the hospitals in question had a year to make improvements to avoid these costs,” HFS Director Julie Hamos said at the time. “Not all readmissions can be prevented, but Illinois hospitals can do better. We hope that this initiative will encourage providers to reduce their potentially preventable readmissions so that Medicaid clients get and stay healthier and the state sees lower costs.”
    The initiative – similar to the federal program which fines hospitals – stems from HFS’ study of Illinois hospitals’ FY 2010 inpatient claims data and trending analysis for 2009, 2010 and part of 2011. The department used 3M’s Potentially Preventable Readmission software to calculate a readmission rate for each hospital, comparing patients’ severity of illness levels at each facility to statewide target levels.
    Risk adjustments were made to include patients’ case mix, age and behavioral health diagnoses, which vary among the populations served by each hospital.
    State officials determined that 147 hospitals had unacceptable PPR levels and thus owed the state under the policy. Of those 147 hospitals, 65 were able to enact measures that lowered their PPR levels significantly and allowed them to avoid paying $18.5 million owed.
    Those hospitals that did not lower PPR rates can either pay the total remaining penalty amount owed or contact the department to discuss a payment plan.
    In addition to a total disruption of their lives, readmitted patients run a real risk of long-term health trauma. Some of the revisits are nothing more than a medicine issue. But others can be longer, depending on complications.
    In Alton, anyone who comes back within a 30-day window is automatically seen by one of the team members, who are notified by email of their return, Magurany said.
    Oddly, some patients go from one Alton hospital to the other, sometimes unexpectedly, which makes the cross-over work done by Noble-Loveland all the more important.
    Neal said she’ll follow up with a phone call after the 30-day period to check on the patient’s well-being as well as see how the program worked and if resources were connected to make sure those are working as well..
    The program locally is only going to grow, with Senior Services Plus reaching out beyond the hospitals, including to individual doctors’ offices, Neal said.
    Anyone wanting more information can reach her at This email address is being protected from spambots. You need JavaScript enabled to view it. or (618) 465-3298, ext. 135.