Too often, vulnerable older adults are left to fend for themselves when it comes to transitioning from the hospital to the next appropriate care setting. Stories abound of people being shipped back and forth from the hospital to temporary care to their homes and back to the hospital again when it all goes wrong. In California, approximately one in five or 81,000 Medicare beneficiaries every year end up re-hospitalized within 30 days of discharge for a medical condition that led to theoriginal hospitalization. This figure increases to 2.5 million Medicare beneficiaries nationally, at a cost of nearly $17 billion a year. These figures do not account for the human, health and financial toll that individuals and their loved ones face when stuck in this revolving door.
Federal and state governments now place increased pressure on the health care sector to provide better quality care while reducing costs, such as readmission penalties and quality ratings on Medicare Advantage plans. However, many of the issues that emerge in the chasm between a hospital discharge and full re-entry at home are things that are beyond the hospital walls. For example, could the person navigate the three steps to get inside the home? If medications need to be taken with food, is there food in the refrigerator? Did the prescriptions get filled within 24 hours in the first place? Does the daughter know how to safely help mom get from the recliner to the bathroom?
These and other key issues are commonplace for a whole range of community-based organizations that answer the calls from frustrated family members and help make arrangements to smooth the transitions. Organizations such as aging and disability resource centers, faith-based groups and many others have much to offer health care systems that can no longer operate only inside the medical walls. Developing, fostering and managing partnerships between community-based organizations and the health care sector is a key step towards addressing the total needs of older adults and people with disabilities as critical junctures in their health. This is particularly true for individuals eligible for both Medicare and Medicaid.
While efforts are underway at the national level to improve care transitions, the dearth of information on how best to build partnerships between the community-based long-term services and supports and the medical sector is staggering. Both the health care sector and community-based services sector have been working on tackling the issue of care coordination, but have been doing so from their own perspectives and biases. Beyond anecdotes, there are few models on how to create, formalize and maintain these partnerships, or how to define and delineate what a joint approach to care transitions and care coordination would look like.
Ultimately, this is part of a bigger paradigm shift in care, one that looks at those who need health care as "people" and not simply "patients." Care coordination and transitions are critical to providing services that should be offered at the right time by the right provider and in the right place. For people whose lives are on the line, this pathway can and should be as smooth as possible. As a physician, I have witnessed firsthand how ugly it is when people end up back in the hospital against their desires when it could have been avoided. The humanity of this issue goes beyond the rhetoric that inhibits health reform. This is really about having the best system in place for those we love -- and ultimately for ourselves.