When you're an older adult, being released from the hospital can be even more daunting than getting admitted in the first place. I've seen discharge instructions so confusing they would befuddle a medical professional, let alone an older adult who may struggle with eyesight, hearing, or even thinking and remembering. Someone else has to assume the burden, of course, and that usually means family members. Either they become caregivers or they do some rapid on-the-job learning about moving a sick older person to a nursing or rehab facility.
What inevitably happens next is the subject of Reed Abelson's recent New York Times article, "Study Finds Many on Medicare Return to Hospital." The title says it all. With poor instructions for aftercare and little or no follow up by doctors, older patients yoyo in an out of the hospital, drive up costs, and end up faring no better with their health.
Eric Coleman, MD, MPH, who developed Care Transitions with Foundation support, is one of the featured study's authors. As he points out in the Times article, physicians have to become more accountable for aftercare. They need to start coaching patients, especially those with chronic conditions like diabetes, to recognize that their health is getting worse. They need to encourage them to take medication and do whatever else is necessary to manage their conditions. And, as one policy specialist notes, Medicare and other reimbursers need to reverse the way they do business by rewarding hospitals for reducing readmissions instead of making it more difficult.
Here at Hartford, we've been focusing on improving transition management through Dr. Coleman's program. Care Transitions uses a Transition Coach and self-management tools to empower patients to take charge of their own care. The intervention also includes informal caregivers as much as possible. By 2007, over 100 hospitals and healthcare systems were using this effective, evidence-based model, and we continue to share it with as many health care systems as possible. If you want to know more about it, see our 2007 annual report.
Care Transitions, along with other programs and Web sites dedicated to caregiving (see below), show that the answers to improving medical transitions and caregiving in general are out there. The question is, how can we get those answers to the people and institutions who need it? And can we do it quickly enough-before the coming wave of older adults completely overwhelms our failing health system?
Caregiving Round-up
The National Family Caregiver Support Program
(Administration on Aging Web site dedicated to caregiving)
Caregiver Support Web sites:
http://www.strengthforcaring.com