The strategies used in the study include student nurses who make home visits, discharge planners who text the physician that a patient is returning home and needs an appointment, and electronic talking scales that electronically transmit weight and other information daily back to the provider.
Other creative solutions that keep costs down, as well as keep patients in their homes, use discharge advocates who coordinate home care with the hospital team and arrange for follow-up appointments.
"Our program has shown incredible results," says Jerry Penso MD, associate medical director of the Sharp Rees-Stealy Medical Group in San Diego, which has 150,000 patients. "We reduced heart failure admissions by over 25% for all of Sharp Rees-Stealy, and the return on investment is $7 to $1."
Mike Kern MD, senior vice president and medical director for the John Muir Physician Network in the San Francisco Bay Area, says daily visits to patients' homes each of the four weeks after hospital discharge has reduced readmissions dramatically there as well, from an estimated 25% to 10-13%.
Kern says that often when elderly patients are discharged from the hospital, they go home and feel insecure. "They will call 911 not because they need readmission, but because they're scared. And that's the only thing they know how to do. And I don't blame them.
"And when they get to the emergency department, the ER's gut reaction is to throw the book at them, work them up, and they're on their way to the inpatient ward," Kern says. "That's often an over-the-top, wasteful way to do it" when many of their issues can be so much more effectively managed at home.
In Eldred's report, many of the included programs have common elements. "Medication reconciliation is critical," Eldred says, "because patients may have medicines at home that interact with the ones they received in the hospital. Someone needs to reconcile all those medications so patients know what they should be taking and what they shouldn't."
Another common strategy is to use nurse trainees or other health professionals to make daily visits to the patient's home, at least for the first few days to make sure they are following the prescribed regimen.
And a third effective tool was to make sure hospital staff engages patients and families to play active roles in managing their health needs.
A study published April 2 in the New England Journal of Medicine found that nearly one in five Medicare beneficiaries were re-hospitalized within 30 days, and on the whole, unplanned Medicare readmissions cost the federal government $17.4 billion.