Program that Reduces VA Hospital Readmissions is Expanding

Madison, Wisconsin - A program that has reduced hospital readmissions by a third for older patients at the William S. Middleton VA Hospital in Madison will be expanding to VA hospitals in Tomah and Iron Mountain, Michigan.


Coordinated transitional care—or C-TraC—involves nurses calling patients two to three days after discharge to check on their condition and review their medication regimen. After that, follow-up phone calls are made weekly for up to a month before patients resume care with their primary care provider. Nurses call patients older than 65 and those with dementia.


According to Dec. 2012 research published in Health Affairs and authored by Dr. Amy Kind, a geriatrics researcher and professor at the University of Wisconsin School of Medicine and Public Health, C-TraC patients had one-third fewer readmissions after 30 days out of the hospital compared to older patients not in the program. It also saved $1,225 per patient over 18 months for a total savings of more than $700,000.


Kind said the C-TraC programs in Tomah and Iron Mountain will be launched in spring 2014 after transitional-care specialists are hired and trained. The program will be funded by a grant that could provide up to $1.5 million over three years. Up to 50 patients at each facility would qualify for C-Trac.


"We need to assess what kind of capacity they have in order to provide necessary care to the patients," Kind said. "The grant will pay for a full-time nurse, a full-time program assistant, and a part-time physician at each site."   


Kind said the weekly phone calls are very thorough and last an average 36 minutes. 


"This is one of the only transitional care programs in the country to target patients with cognition and those with dementia," she said. "Studies have shown that within a few days after discharge, patients are already taking their medications the wrong way and not the way they were prescribed in the hospital. Patients who are called a couple of days after discharge may say over the phone they understand their plan and know what’s going on, but if you dig deeper and ask them what the plan is, half of them have trouble remembering it. Transitional care truly does the best job of helping patients take care of themselves."


Kind said C-TraC is an extra step in making sure discharged hospital patients have proper control of their own health care.


"The traditional health care culture over the last 25 years has been to discharge the patient and just assume everything will be followed up appropriately," she said. "Yet, that assumption is false. It’s important for patients to communicate understanding of their health care."

Date Published: 10/08/2013

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