Bridging Elderly Patients from Hospital to Home

  • Medicine & Health
  • 2009

Research has shown that one third of Medicare patients who leave a hospital will be readmitted within 90 days, and that a large portion of these rehospitalizations are unnecessary, due to things like patients not taking their medications properly. The costs of these elderly patients churning in and out of hospitals are high: unhappy patients, burdens on family members, and tens of billions of dollars in public health-care expenses. Studies in 2008 and 2006 estimated that patients unnecessarily returning to hospital within just the first 30 days cost a total of $49 billion.

To combat this, health-care providers at the University of Pennsylvania developed what they called the Transitional Care Model, which used nurses to train patients and caregivers in how to manage their medications and therapies and avoid future health issues, and then make sure in home visits that the instructions are being followed. This was not a program for long-term care, but strictly an effort to bridge between the hospital experience and the first months back at home. When the effort proved very successful, a program was launched to demonstrate the cost-effectiveness of this approach to insurers and health-care operators. This was done with financial support from five philanthropies: the Commonwealth Fund, the Jacob & Valeria Langeloth Foundation, the John Hartford Foundation, the Gordon and Betty Moore Foundation, and the California HealthCare Foundation.

Careful academic studies showed powerful results: improved health, greater patient and caregiver satisfaction, and a whopping 30 to 50 percent reduction in rehospitalizations, heading off unnecessary costs of nearly $5,000 per patient. When the program costs of $456 to $1,019 per patient are factored in, net savings came to approximately $4,000 per elderly participant. With this evidence in hand, health insurers began voluntarily integrating transitional care models into their coverage plans starting in 2009.