The patients may have literacy or language challenges or be living with a spouse who has health issues as well. And Merrimack added mental health outreach, because it found that within its population, depression that produces anxiety and pain can often mean a trip back to the hospital.
Moreover, making sure patients obtain their prescribed medication can present a challenge. Healing@Home and the Area Agency on Aging in Maricopa County, AZ are working with Sunwest Pharmacy and four Phoenix area hospitals to address that issue. Sunwest delivers prescription drugs to program participants unable to obtain their medication themselves.
It's good to see that at least some hospitals recognize some benefits from these partnerships, because that wasn't the case when I inquired about this program last fall. One hospital official suggested she couldn't imagine that a CBO, or Area Agency on Aging in her town could manage the post-discharge needs of a morbidly obese patient with diabetes and congestive heart failure.
Of course, the program will require close monitoring for unintended consequences. We need to be sure patients aren't dying at home because of an overaggressive effort to prevent a readmission, or that groups of patients aren't reappearing at the hospitals' doors on day 31.
But as a policy official familiar with the issue once explained, these hospitals are well aware that community factors provoke a lot of readmissions that hospitals can't begin to address.
It is a grand experiment, but one that just might work. It may indeed take a village to keep a patient from being readmitted.