Dolores Griffis, a petite 80-year-old woman, leans against her walker as hospital volunteers unpack fresh strawberries and bananas in her apartment kitchen. "If you need anything else, let me know," says Nisha Mandani, an ebullient 44-year-old woman who is putting away the groceries with the help of her teenage son. "If you need milk, any medications, just let me know." Their goal is to keep Griffis, who has cycled in and out of the hospital for years, from going back yet again for reasons that could be avoided.
It sounds simple, but any number of small missteps could lead Griffis to another emergency room visit. Heart failure, small strokes and a slow-healing broken back top her list of medical problems. She takes multiple medications and uses an oxygen tube 24 hours a day.
Scores of seniors in similar circumstances have produced an alarming national statistic: According to Medicare data, about one in five senior citizens re-enter the hospital within a month of a discharge. One in three went back within 90 days, according to a study recently published in the New England Journal of Medicine.
This high readmission rate among the elderly has the attention of President Barack Obama and Congress as the nation debates the costs of health care reform. Some repeat visits are unavoidable, but government research suggests many could be prevented with better communication and coordination.
Potentially preventable readmissions within a month of discharge cost the nation $12 billion in 2005, according to the Medicare Payment Advisory Commission. Such dollar figures, of course, don't count the emotional toll.
Tampa Bay area hospital system Morton Plant Mease Health Care wants to be on the front lines of finding solutions. It is participating in a national project aimed at preventing these readmissions. It is focusing on communication gaps that can occur during hospital discharge — between doctors and patients, and even doctor to doctor.
"Too often patents go home, they're confused, they're not sure about their medications, and their medical condition deteriorates until they are so sick they have to call 911," said Northwestern University's medical school.
Of course, few are concerned with the economics of health care when a loved one enters the hospital. Caretakers can be overwhelmed just dealing with the experience and what happens next.
"You don't really understand this issue until you live through it and you see what this transition home is like," said Lori Parham, state director for AARP Florida, which is lobbying Congress for a transitional care benefit. "We're asking caregivers to provide round-the-clock care."
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Griffis recently celebrated the one-year anniversary of her last visit to Mease Dunedin Hospital, no small victory for a widow whose children live out of state. She credits the volunteer she calls "my angel" with playing a big role in helping her to break the cycle.
Mandani showed up at Griffis' apartment after hospital staff recommended her for "Friend to Friend," a program in the four regional hospitals that make up the Morton Plant Mease Health Care system. The program targets patients at high risk for hospital readmission.
Mandani and her 13-year-old son go grocery shopping weekly for Griffis, who no longer drives. They take out her garbage. They bring in mail that collects in a remote box at her Palm Harbor apartment complex. During the week, they may also pick up medications and meals for her.
The visits lift Griffis' spirits. Once Mandani gave her a bottle of White Diamonds perfume.
Mandani acts as a line of defense against problems that could lead Griffis back to the hospital, like poor nutrition and an inability to get medications. In her visits, she also can catch small things that could make a big difference.
On a recent visit, Mandani's son, Ishan, tinkered with Griffis' electric scooter, which hasn't been working lately. He figured out that the armrest was in the wrong position.
"I haven't used it in so long, I forgot how to use it," Griffis said.
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The Mease hospitals, like others nationally, believe they can do more to prevent repeat hospital visits for older patients.
This spring, Morton Plant Hospital was selected to participate in Project BOOST, or Better Outcomes for Older adults through Safe Transitions. Nationally, 30 hospitals are involved with the initiative of the Society of Hospital Medicine.
Morton Plant will receive year-long coaching and a host of tools to tackle the issue. Messler, one of the project leaders, hopes to try out concepts at that hospital that could extend to others in the system in the future.
Among the approaches Morton Plant is considering:
• A phone call to patients 24 or 48 hours after discharge to see how they are doing, discuss medications and any problems.
• Asking patients and caregivers to "teach back," or repeat to medical professionals the highlights of what happened in the hospital, checking that it was really understood.
• Making sure information passes between the hospital and the primary care physician about diagnosis, changes in medication and any follow-up tests and appointments needed.
"We're trying to solidify the hand-off," said Messler, noting that some things already are in place, just not systematically. "These first few weeks, the first 30 days, are the more vulnerable period."
During that time, he noted, patients may not have yet made it to their primary care physician. More coordination could help make sure those visits happen.