Fourteen communities nationwide are participating in a pilot project that aims to reduce Medicare costs by preventing frequent hospital readmissions for chronically ill beneficiaries. According to a report in Louisiana's Baton Rouge Advocate, whose home city is one of the pilot sites, the program focuses on hospital discharge procedures involving patients with pneumonia, heart attack and congestive heart failure. Under the Care Transitions Project, patients meet with a "transition coach" who will provide them with information about staying healthy. Coaches help patients create a list of questions for their primary care physician, develop a self-care plan and discuss questions about medications. Patients meet with the coach before leaving the hospital and 48 hours after they are discharged, with additional follow-ups one week, two weeks and one month after being discharged.
Monday, March 16, 2009