Hospitals reach out to keep patients from returning

Of the caregivers who visited John Boyce's room at Penn Presbyterian Hospital, Sharon McCollum might seem the least likely to belong. As Boyce lay there for the second day, McCollum said she would help with anything - except medical care.

McCollum is a community health worker in a new program that helps poor West and Southwest Philadelphia residents. The goal: Keep patients from returning to the hospital.

After handing Boyce a pillbox for medications and a calendar for appointments, McCollum sat down and asked "What brings you in?" Boyce, 60, of West Philadelphia, gingerly touched the lump on his neck that would later be diagnosed as skin cancer. McCollum asked more questions, discovering he had no health insurance or primary care doctor. When she asked him to recall his last doctor visit, Boyce closed his eyes. "A year ago?" he replied.

McCollum then switched gears. Did Boyce, who works at the West Oak Lane Senior Center, have problems with his house? (Some weatherization and electrical issues.) And did he have enough to eat at home? ("I can fry you up some chicken," he said.)

By the end, McCollum identified a half-dozen "pathways" she would help Boyce traverse, from securing insurance to finding transport for doctor visits. McCollum jotted down his cellphone number. "If I call you and your phone is disconnected, I'll be at your front door."

Hospitals are reaching out to patients such as Boyce because they are trying to stop readmissions. Medicare alone paid more than $17 billion for unplanned hospital readmissions over 15 months, a 2009 study found. The government plans to start penalizing hospitals in 2013 for above-average readmission rates for certain medical conditions.

Penn's effort is not unusual. Forty-seven local hospitals and other groups recently ended an 18-month project to cut readmissions. Preventing Avoidable Episodes helped its hospitals lower 30-day readmission rates 7 percent, according to the Delaware Valley Healthcare Council.

Shreya Kangovi, the internist who started Penn's program, said the new penalties would lead more hospitals to work with health workers. "Because so much of what drives readmissions happens outside the hospital, this is really the only way to go."

Penn's Patient-Centered Transition Project targets five zip codes - 19104, 19131, 19139, 19143, and 19146 - accounting for 85 percent of the system's readmissions. One in three residents there live in poverty, she said, making them eligible for her program. "It's a zip-code problem and a dollar-sign problem," not a disease problem, she said.

Since its launch in May, more than 260 patients have come through the pilot program, a partnership with Spectrum Health Services.

Practicing for five years, Kangovi grew accustomed to seeing poor patients get discharged without handling such issues as child care and medication costs. "We look at them and just see their blood pressure," she said, "but the reality of everyday life is a huge gap we're not filling."

The problems did not require an MD, so Kangovi hired two health workers who meet with each patient four times typically over two weeks. At the first meeting, in the hospital, the health worker evaluates the patient's needs. At discharge, the worker helps with understanding nurse instructions.

Once the patient is home, the worker visits to help solve issues. And the worker accompanies the patient to his first posthospital doctor visit.

In a recent Rhode Island study, patients had a 39 percent drop in readmissions after receiving at-home education from trained health coaches - nurses, social workers, and one layperson, said Stefan Gravenstein, a medical professor at Brown University. Among other skills, he said, the coaches taught patients how and when to take medications.

The layperson, who had a high school education, was "every bit as effective" as the other coaches, Gravenstein said. He said he believed the Philadelphia program would succeed, though teaching patients to record their conditions and medications might help.

On a rainy November afternoon, health worker Mary White visited her patient at home in Point Breeze. Migdalia Reyes, 57, battles diabetes and other chronic diseases, and she was hospitalized after a recent fall. A friend said Reyes needed a referral for her forthcoming primary care visit and she feared not having the proper paperwork. "Don't worry about it," White said. "I'll be there." White asked Reyes if she held onto a copy of her hospital-discharge report. She had not. "That's why I made copies," White said.

Reyes appreciated the help. "I don't have no kind of family here," said Reyes, who is from Puerto Rico. "I need somebody to talk to." And when she least expects it, White calls. "It's nice to see that somebody is there for you," Reyes said.