Q&A Preventing rehospitalizations of older adults

Question: My sister, 78, was recently in the hospital for shortness of breath due to Chronic Obstructive Pulmonary disease (COPD). She was released after a few days, but with a list of prescriptions she couldn’t pick up and didn’t understand, and was sent back to her apartment with its empty refrigerator and steep, icy staircase.

I’m an hour’s ride from my sister’s place, so while I help out as much as I can, the drive is too much for me sometimes. What I want to know is why there’s no program to help my sister make the transition out of the hospital back home. Without help, she’s bound to end up back in the hospital in no time.

Answer: You’re right. For a long time, one of the biggest problems with our health care system has been preventable rehospitalizations. Too often, people—particularly seniors—are put into your sister’s situation: sent home from the hospital with no support, no groceries, and no one checking in on them to ensure their safety, all of which contribute to the high rehospitalization rates for older adults.

For these reasons, I’m truly excited to tell you about a relatively new initiative in the Mystic Valley region: four non-profit health care and social services organizations are teaming up to ensure that seniors have the full supports they need to leave the hospital, return home safely, maintain their health, and avoid going back to the hospital. The Mystic Valley Basin Care Transitions Collaborative includes Mystic Valley Elder Services, Somerville-Cambridge Elder Services, Hallmark Health System (Lawrence Memorial Hospital and Melrose Wakefield Hospital) and Cambridge Health Alliance (Whidden Hospital and Cambridge Hospital).

The Care Transitions Collaborative was formed with the goal of decreasing the likelihood of rehospitalizations. Through the Collaborative, Medicare patients who have been admitted to the hospital for three or more days or who have a diagnosis of heart failure or Chronic Obstructive Pulmonary Disease (COPD) will be assigned to special Transition Facilitators. These Transition Facilitators will work closely with the patients to make sure that they understand their prescriptions and have a plan to have them filled; and that they have the support they need upon return home, either through family, friends, or one of the elder service agencies. The Transition Facilitator will help the patients make follow-up appointments with their doctors and arrange transportation, if necessary, to the medical visits; Transition Facilitators will also visit the patients at home to make sure they have what they need; and will continue to work with the patients for 30 days after release from the hospital. Increased nursing supports will also be available to those patients who need a little extra help.

The Care Transitions Collaborative provides these services at no cost to the patient. Currently, Care Transitions Services are available to Medicare beneficiaries (including those under 65 years of age) who are served by one of the four hospitals listed above regardless of where they reside.

For information about this program or any of the services offered at Mystic Valley Elder Services, call us at 781-324-7705.