Hospital follow-up falls short

Esther Vicente was in and out of the hospital three times last summer, first with a serious liver ailment, then to treat an infection related to the liver problem and finally to have her "angry" gall bladder removed.

But just as agonizing as the 73-year-old's medical complications were those she faced after doctors decided it was time to leave the hospital. She hadn't felt ready to go home, especially without the information and support she needed to properly heal.

Vicente's experience is common and one that too often leads to extended nursing home care, readmittance to the hospital or even premature death, said Allison Ruff, a gerontologist and principal consultant to the California Assembly Committee on Aging.

"Hospitalization can be a turning point for older people and their caregivers," Ruff told Vicente and members of the Sacramento Older Women's League at their meeting Saturday. "All too often, they are the recipients of fragmented care."

Problems moving patients from the hospital back home or into skilled nursing facilities have received increasing attention from senior and health care advocates the past couple of years, and a handful of innovative programs have evolved to smooth transitions for hospitalized patients.

But strained budgets, weak state statutes, overwhelmed hospital discharge planners and Medicare's failure to pay for better coordination of post-hospital care have stymied efforts to fully address the problems, Ruff and others said.

"It's only going to get to be a bigger problem," Ruff predicted.

That's because people 65 and older are the fastest growing portion of the U.S. population. By 2050, the number of seniors is expected to more than double to 87 million.

A 2006 study about health care transitions by Health Research for Action at UC Berkeley concluded that transitional care is rarely coordinated, leaving patients to fend for themselves as they move from hospital to nursing home or back home.

Although state law requires hospitals to give patients telephone numbers of local senior agencies, Ruff said they are not required to assess a patient's home to see if it's safe or to line up in-home services for follow-up care.

"Time and time again, we see people have been told it's time to go home and they don't feel ready," said Jodi Reid, of the California Alliance for Retired Americans, a San Francisco-based advocacy group.

"They are still recuperating, or the care instructions are too complicated. We know dozens who wound up back in the hospital because they were sent home too soon."

In Vicente's case, the in-home helpers assigned to her case were either inadequately trained or simply unreliable.

She never got nutritional counseling she expected and was not sent home with medical supplies needed to prevent a postoperative infection.

The UC Berkeley report also found that hospital discharge planners are overwhelmed and that hospitals do not invest enough in making sure they can adequately do their jobs for patients.

Kate O'Malley, a senior program officer at the California Healthcare Foundation, explained that hospitals can't bill Medicare for preparing a patient for discharge, so that process often gets short shrift.

Instead, because of the way hospitals are reimbursed for Medicare patient care, they are financially motivated to send patients home as soon as possible, even if it means the patient is likely to return with the same diagnosis for another costly hospital stay.

"The financial incentives in health care are perverse in terms of supporting a good discharge process," O'Malley said.

At the end of her third week-long hospital stint, Vicente said she didn't feel ready to go home but was told by the nurse that the doctor had ordered her discharge.

Vicente and her family didn't know – and say they were not informed by the hospital – that Medicare patients can appeal their discharge order by making a single telephone call to Lumetra, an organization contracted by the federal government to review such appeals. The process can buy extra time for patients who need to set up the delivery of meals, in-home nursing care or even a ride home from the hospital, Ruff said.

The UC Berkeley report also found that people who wind up taking care of loved ones after they leave the hospital are seldom equipped with the training they need to do the job well.

Vicente said her husband is partially blind, and the daughter who came to help her didn't feel she had the expertise to safely manage her mother's fragile condition.

"They didn't prepare us ahead of time," Vicente said.

The senior advocates said there are good models that address transitional care for older patients, including Sutter Health's PACE program and the Multipurpose Senior Services Program run by UC Davis.

But they predicted that until improvements are fully funded and can be put in place in every county, problems will persist.

In the meantime, said Reid, consumers should learn their rights and be prepared. "It could mean the difference between recovering well or not," she said.

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