Two hospitals in the region surrounding New York State's capital have met Medicare's standard for reducing readmissions and will not be penalized with lower reimbursement payments, reports a September 6, 2015, Times Union (Albany) article. According to the article, this status puts the facilities in the minority in both their state and the country, with approximately 77% of New York's hospitals receiving penalties along with more than half of the nation's hospitals. Hospital officials at both facilities credited their success to multiple initiatives that help patients navigate the health system, find a primary care doctor or insurance coverage, and provide follow-up guidance and help with managing their conditions after discharge. One of the hospitals has created a department called "Care Central" that employs a staff of nurse "navigators" to help patients with such needs, including transportation to doctors. In other programs, staff provide education to asthma sufferers to help them manage their condition, palliative care to patients with advancing chronic illness, and house calls to patients whose conditions put them at a higher risk of hospital readmission. The other hospital employs a team of nurses called "transitional care managers," who contact patients at risk for readmission to make sure they receive intended care post-discharge, such as seeing community doctors for follow-up visits, getting prescriptions filled, scheduling physical therapy in their home, or ordering a wheelchair. The article notes that hospitals' task of lowering readmission rates is made extremely challenging by Medicare's method of data analysis, which, for example, counts a patient's readmission within a month even if the patient returns for something unrelated to the original illness, such as an injury from an accident.

HRC Recommends: Communication across the continuum of care can help to improve the quality of care provided and reduce readmissions. Helping patients to understand their healthcare goals and to reach them is another key part of this effort, as demonstrated by the hospitals described above. Even patients with generally high health literacy may have trouble understanding health information at times, and patients may be affected by acute or chronic medical conditions, fatigue, stress, lack of support at home, or a number of other factors. Risk managers should investigate how their organization evaluates and supports patients' ability to care for themselves after discharge and determine ways to support patients' healthcare efforts.