Rio Grande Valley to be part of study to cut hospital re-admissions

HARLINGEN -- The federal agency that oversees Medicare has chosen the Rio Grande Valley as one of 14 sites to test a nationwide program that would cut down on re-admissions to the hospital and improve patients' health.

Of the approximately 13,000 Medicare patients hospitalized each year in the Brownsville, Harlingen and Weslaco areas, about one-fourth return to the hospital within 30 days, according to organizers of the new initiative. Many of those re-admissions are preventable, they said.

"We saw it as an opportunity for real improvement," said Kevin Warren, senior vice president of operations for the Austin-based TMF Health Quality Institute, an organization that works with hospitals and doctors to improve health care quality. The federal Centers for Medicare and Medicaid Services has contracted with the institute to launch the Care Transitions project in Brownsville, Harlingen and Weslaco.

The three-year project will recruit people from community organizations, hospitals, home-health agencies and even promotoras, or community-health workers, to serve as "transition coaches," organizers said. These coaches will help patients take charge of their health care after leaving the hospital, said Dr. Jane Brock, chief medical officer for the Colorado Foundation for Medical Care. Brock is in charge of a pilot project in Colorado that will serve as a model for the Valley project.

Usually in the hospital, the doctors, nurses and providers do everything for the patient, but that changes once the patient leaves the hospital, Brock said. Once the patient returns home, he or she might have questions about their medications, misunderstand doctors' orders or decide not to follow the advice, she said. Eventually, they often land back in the hospital.

"They might not know how to self-manage their care or know who to call if they have questions," Brock said.

A transition coach meets with patients before they leave the hospital and then within 48 hours of leaving. The coach helps the patient put together a list of questions for the doctor, discusses questions the patient might have about medications and helps the patient put together a plan for self care, Brock said.

Brock said that the coach "reconciles the doctor's discharge summary with the patient's goals," because often, the patient has his or her own goals for recovery that might not mesh with the doctor's.

In addition, the coach helps patients put together a personal health record with a medical history that the patient carries at all times.

In the Denver-based pilot project, the use of transition coaches helped reduce re-admissions to the hospital by half, organizers said.

"Long after the coach was gone, coached patients did better," said Emile Fennell, a spokeswoman for TMF Health Quality Institute.

The Centers for Medicare and Medicaid Services is funding projects like these so the agency can cut down on Medicare spending and reduce the high readmission rate for Medicare patients, Warren said.

"The purpose is to see, at a national level, how we can begin to address this issue," he said. "How can we save these precious health care dollars and how do you improve quality of life for the community?"

The institute selected the Brownsville-Harlingen-Weslaco area for several reasons, Warren said. For one, most patients stay within those three cities for hospital care, making it easier to track the impact of the program on their readmission rates. The community is also close knit, with families and community groups heavily involved in patients' care, making it an ideal place to test out the coaching model and other ideas, he said.

The region also has a high rate of utilizing health care services, Warren said.

According to the Dartmouth Atlas of Health Care, a research project of The Dartmouth Institute for Health Policy and Clinical Practice in Lebanon, N.H., the Harlingen area ranks second in Texas in "intensity" of hospital services -meaning the region relies heavily on placing patients in the hospital for care.

The McAllen area ranks first in Texas.

Organizers decided to focus solely on Harlingen-Brownsville first because the region's patients seem less likely to leave the area for care, Warren said. By expanding the project to include McAllen, it becomes harder to track patients' movements among hospitals, he said.

The project ultimately will involve more than just "transition coaches" in hospitals, said Jennifer Markley, Care Transitions project director. Participating hospitals and doctors' offices will look at the trends they see among their patients and then meet at a conference to talk about how they can better coordinate patients' care to reduce readmissions, she said.

TMF also plans to hold educational programs at senior centers and other facilities to educate them on managing their health care, Markley said.

Most hospitals in the Harlingen-Brownsville-Weslaco area have expressed interest in participating in the project, Markley said.

If successful, the project could change the health care landscape in the Valley, Warren said.

"The way to change health care isn't just to focus on the provider ... the community needs to play a role, too," he said.

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Melissa McEver covers health and environment issues for Valley Freedom Newspapers. She is based in Harlingen and you can reach her at (956) 430-6252.