Across the country, large numbers of people are readmitted to hospitals within 30 days of discharge or end up moving unnecessarily to a nursing home. Problems such as misunderstanding how to take medications, confusion over when to call the doctor and for which symptoms, a lack of resources to remain at home or even ineffective discharge planning by the hospital or nursing home can create these scenarios.
Readmission to hospitals is a serious national health care challenge. As a result, hospitals nationwide must find ways to reduce their 30-day readmission rates or they may face non-payment from the Centers for Medicare and Medicaid Services (CMS).
When the Howard County Office of Aging received a grant from CMS — the “Person-Centered Hospital Discharge Planning Model” (PCHPD) — to help reduce hospital readmissions, it collaborated with Howard County General Hospital (HCGH) and hired Katherine Dysland, R.N., as a patient transition guide to assist Medicare and Medicaid patients being discharged to their homes. The program targets individuals on Medicare or Medicaid, who have a much higher risk of readmission to the hospital or potential for long-term admission into a nursing home.
Hospital case managers, social workers, nurses and doctors refer potential candidates to Dysland, who meets with patients while they are in the hospital and works with them after discharge to ensure that they understand their medication regimen and that they follow up with their doctor.
“I teach newly-discharged patients how to reconcile their old and new medications,” she explained, “and on a home visit, I try to create one master list with all medications they need to take and all the correct dosages and tell them to bring this list to all doctor appointments.”
Providing information and education is also an important part of Dysland’s role as a patient transition guide.
“Patients need to understand their medical conditions and the importance of following up with their family doctor. They’re often confused when they leave the hospital, so a home visit helps them to better communicate and advocate for themselves,” she said. Dysland also coaches patients on when it is important to call their doctor, as getting attention early on can reduce the need for readmission.
To further assist individuals and families after hospitalization, Dysland works closely with the staff of the Maryland Access Point (MAP, the Aging and Disability Resource Center of the Office on Aging) and the Senior Health Insurance Assistance Program (SHIP). MAP staff provide expert resource assistance for individuals, caregivers and professionals on a variety of topics such as in-home care and respite options, transportation options, health and wellness classes, home modifications, public benefits exploration and more. SHIP staff and counselors work closely with community residents to help them navigate the Medicare system and to understand their health insurance options.
Often, people are most vulnerable after a hospitalization; knowing how and where to access resources, such as short-term in-home help, may mean the difference between a successful recuperation and a relapse, which would require a return to the hospital.
In an effort to expand their partnership, the Office on Aging is currently working with HCGH to have a MAP specialist stationed at the hospital. The immediate goal is to have a specialist on-site who can be available to patients, their families and hospital staff to explore community care options and provide resource information.
The Office on Aging, through Maryland Access Point, provides information and referrals to community resources for individuals age 18 and older, regardless of income or disability, to help them achieve the best possible quality of life in Howard County. For information and assistance, contact Maryland Access Point at 410-313-5980 or e-mail map@howardcountymd.gov. For information or questions about Medicare or other health insurance, contact the Senior Health Insurance Assistance Program (SHIP) at 410-313-7392.
Dayna Brown is administrator of the Howard County Office on Aging. She may be reached at 410-313-6410.
