If you want to avoid a trip back to the hospital, help at home is key, study shows

Seniors leaving the hospital are less likely to return within six months if someone who will care for them at home talks with the hospital about the patient's needs before discharge, according to a University of Pittsburgh analysis published today.

Older patients who left hospitals with a post-discharge plan were 24 percent less likely to be readmitted in six months than those who didn't have discharge plans, according to the analysis, which reviewed 14 studies of seniors with a mean age of 70. The Journal of the American Geriatrics Society published the analysis.

The analysis comes as Pennsylvania's Caregiver Advise, Record, Enable Act, known as the CARE Act, is scheduled to go into effect next month. The law requires hospitals to ask patients upon discharge if they would like to identify a caregiver. If they do, the hospitals must familiarize the caregiver with the care the patient will need.

As baby boomers retire and people live longer, more seniors are living at home with complex medical needs. Family members and friends provide the majority of at-home care in the United States, making it important for the health care system to support their work, according to aging experts.

“Hospital discharge planning is critical for helping family members understand what they need to do to help keep their patient or loved one in the community,” said Juleen Rodakowski, the lead author of the analysis and an assistant professor in Pitt's Department of Occupational Therapy.

Most Pittsburgh-area hospitals already help patients plan for discharge, hospital quality officers from UPMC and Allegheny Health Network said. Avoidable re‑admissions are a target in efforts to reduce health care costs and improve hospital quality, and Medicare and private insurers use penalties and incentives to try to reduce readmissions, often targeting the 30 days after discharge. Medicare spends an estimated $12 billion per year on potentially preventable readmissions, according to the study.

Rodakowski said the study raises more questions for future studies, such as what kind of post-discharge care is most effective and which types of medical conditions benefit most from post-discharge care.

“I would think that more complex persons with multiple illness and serious health issues are going to benefit the most,” said Linda Waddell, UPMC's senior manager for quality and crisis intervention.

The hospital system includes diabetes educators, nutrition specialists, physical therapists and other experts in the discharge planning process, Waddell said. Tasks such as giving insulin and tube feeding can require training to do it properly, she said.

Waddell said she thought the state law could bring more attention to the importance of post-discharge planning.

“I think sometimes patients don't even think about who can help them at home. This may change how people think,” she said.

Mark Naylor, 60, of Wexford said the instruction he received in his father-in-law's rehab during a stay at St. Clair Hospital turned out to be important for the 90-year-old's health.

While his father-in-law, Albert Badzgon, received the same training, he was less inclined to follow the instructions, Naylor said. Naylor reminded him to sit down in a car in a way that wouldn't damage his joints and kept him from climbing stairs before the doctor had authorized the activity.

“I think if it wasn't for the training and exercise they showed us there, I wouldn't have known enough to be firm about saying, ‘No, you have to do it this way,' ” he said.

Representatives from both hospital systems said they start discharge planning shortly after hospital admission.

Average stays are two to five days at AHN hospitals, said Sam Reynolds, the system's chief quality officer.

Care coaches are tasked with making sure patients get the care they need after discharge, Reynolds said. The managers might connect patients with social workers if they learn the patient won't be able to afford medication or followup care. The hospital system makes sure patients understand their medication regimen and make sure that they schedule an appointment with their primary care physician before discharge, Reynolds said.

“This is certainly a national initiative to reduce readmissions, and we are working every day to continue to improve our performance around this,” he said.

Wes Venteicher is a Tribune-Review staff writer. Reach him at 412-380-5676 or wventeicher@tribweb.com.