Transitional care included in health overhaul package

CONCORD, N.H. (AP) — Home health care providers in New Hampshire and Maine are praising a provision of the health care overhaul legislation that would expand upon their efforts to keep elderly patients out of the hospital.

The provision, sponsored by Sens. Jeanne Shaheen, D-N.H., and Susan Collins, R-Maine, would create a transitional care benefit for Medicare recipients. The goal is to provide follow-up care for patients after they leave the hospital in hopes of preventing costly re-admissions. Typical services might include help figuring out when to take medication, scheduling follow-up appointments or coordinating support services such as meal delivery or transportation.

While many patients already receive such care now through a home health benefit, many others do not because they aren't considered homebound. Expanding those services to more people makes sense given the potential to both reduce costs and produce better outcomes, said Mary Deveau, president of Concord Regional Visiting Nurses Association.

Transitional care also gives providers an immediate look at what patients are really experiencing, she said.

"When you go to the emergency room or a doctor's office, somebody can tell you, 'Oh, yeah, I took my meds, I'm eating great.' But boy, when you go in and say, 'Can I see your refrigerator?', you can see the fried foods ... the canned foods that have lots of sodium," she said.

A New England Journal of Medicine study conducted last year found that nearly one-third of Medicare patients who were discharged from a hospital were re-admitted within 90 days largely due to lack of follow-up care. In Maine, nearly 20 percent of Medicare patients who are hospitalized wind up back in the hospital within 30 days, Collins said. But Deveau and other home health care workers said a little education and intervention can go a long way toward reversing that trend.

At Concord Hospital, Dr. B.J. Entwisle runs a program that sends physicians into the homes of about 60 elderly patients to help them manage not only their medical conditions but overall frailty — day-to-day difficulties with cooking, bathing, using the phone.

"They really get to know these people and bond with them," she said. "The patients love it."

The proposed transitional care benefit sounds like a good idea, she said.

"Ideally, we would be arming (patients') own primary care doctors to do it," she said. "Sometimes there are great ideas, but disjointed care."

Donna Deblois, executive director of Kno-Wal-Lin Home Care and Hospice in Rockland, Maine, said she and some of her peers from other agencies will go to Washington next month to educate members of Congress about the role of home care workers in managing chronic disease, transitional care and reducing accute care hospitalizations.

She views the proposal from Collins and Shaheen as enhancing something home health care workers already do well.

"The focus of home care is teaching and to get people back to the level they were at before. We can take care of diabetics without them ever going into the hospital," she said. "Home care in the scope of things is cheap."

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Just one of the many cost

Just one of the many cost cutting ways health reform will save money and lives.

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