July 31, 2013
Former U.S. Navy corpsman and John C. Lincoln transition coach Kathy Orona, right, checks blood pressure of Medicare patient Kathleen Reed during a wellness visit following Reed's release from John C. Lincoln Hospital. Reed's health check results are being recorded into her electronic medical record by John C. Lincoln transition coach Letty Fred, also a former U.S. Navy corpsman.
Love, they say, makes the world go round. Apparently, at John C. Lincoln love also reduces hospital readmissions by frail Medicare patients.
A program that hires military combat medics and corpsmen to care for discharged elderly patients like beloved grandparents has slashed the John C. Lincoln Hospitals' Medicare patient readmission rates to an astonishing 6 percent.
It's not that the rates were bad to begin with. Before the program started last October, the Medicare readmission rates at John C. Lincoln Hospitals hovered around a respectable 18 percent — the national average is 20 percent. Those readmissions cost the federal government more than $17 billion annually.
The Centers for Medicare and Medicaid Services (CMS) launched a campaign to encourage hospitals to do whatever necessary to maintain the health of discharged Medicare hospital patients with congestive heart failure, heart attacks or pneumonia, so fewer of them would be readmitted within the first 30 days after leaving the hospital. Financial incentives for readmission rate reduction and penalties for readmission rate increases were built into the CMS campaign.
John C. Lincoln's innovative response to the CMS challenge mobilizes a cadre of veterans as transition coaches who provide designated Medicare patients with a personal touch along with support and guidance — to help them with follow-up medical instructions, prescription drugs, doctor appointments, nutrition and costs of care.
In the long run, reduced readmissions generated by the transition coaches produce significant savings for John C. Lincoln that far exceed program costs. But initial assistance to maximize the program's effectiveness was needed.
The Del E. Webb Foundation stepped into that gap and awarded a $500,000 two-year grant to John C. Lincoln Health Foundation to support and expand the Health Network's transition coach services. The grant will provide $250,000 this year to hire an additional five coaches, plus an additional $250,000 in July 2014 to hire five more, bringing the total number of John C. Lincoln transition coaches to 14.
The additional coaches make it possible to provide transition services not only to designated Medicare inpatients, but to all frail elderly patients being discharged from both hospitals, regardless of Medicare status or membership in John C. Lincoln's Accountable Care Organization.
"But our primary goal is not to chase statistics," says Transition Coach Program medical director John Lees, DO. "It is to reduce readmissions by helping at risk patients.
"Our first goal is to take care of discharged patients the way their own children or grandchildren would take care of them . . . to love on them and make sure their food, safety, medication, follow-up doctor visits, transportation or other everyday needs get taken care of, so their health is maintained, so they don't relapse for preventable reasons," Dr. Lees said. "Our goal is their optimal health."
A key component, Dr. Lees said, is hiring transition coaches from the pool of trained military medics and corpsmen returning from active service in the Mideast. In spite of their rigorous training and experience, these soldiers are considered unqualified for most civilian health care positions. John C. Lincoln is providing employment relevant to the work they did in the field while harnessing their abilities, knowledge and disciplined initiative to address the needs of discharged Medicare patients.
Using the strategic, creative and responsive skills learned during military service, the transition coaches work with patients in the following major areas:
- Medication self management: Making sure patients have access to pharmacies, can afford to their prescriptions, know how and when to take their medications, and understand the drugs' purpose and potential side effects.
- Physician follow-up: Making sure the patients know when to see primary or specialty physicians for follow-up care, that such visits are scheduled and that the patient has needed transportation.
- Patient-centered health records: Teaching the patient to use a personal health record with a computer or smart phone to facilitate communication and continuity of care.
- Nutrition and home safety: Making sure the patient and pets have adequate healthy food so that malnutrition doesn't impair recovery; checking the home for hazards that can lead to falls or other injuries.
- Red flags: Making sure the patient recognizes symptoms that indicate his or her condition is worsening and knows what to do to get help.
These services, none of which involve medical care, are essential to the preservation of patients' health, Dr. Lees said.
"Many have asked why our program is so much more successful than other hospitals' efforts to maintain the health of their discharged Medicare patients," Dr. Lees said. "We're still evaluating our experience to find out why."
However, some factors the transition team believes are crucial to their success include:
- Veterans relate well with patients.
- Veterans are geared to recognize and solve problems, traditionally or out-of-the-box, creatively and immediately.
- Transition coaches with access to John C. Lincoln's electronic health records system don't have to rely on their patients for health history, medication review or other information, because all that can be accessed on a computer, laptop, tablet, iPhone or Android. Follow-up doctor appointments or prescription refills can be made expediently online.
"We are enthusiastic about our initial success," Dr. Lees said, "and we hope that our program, the national winner of the 2012 White House Healthcare Policy Challenge, will be recognized as a best practice that will become a model for the nation.
"There are currently more than 20,000 military combat medics and corpsmen returning from Iraq and Afghanistan who need jobs and who could help preserve the health of Medicare patients released from hospitals across America," Dr. Lees said. "Wouldn't it be ideal if they could do what our transition coaches are doing?"
Return to main News page.