Mid-Michigan's healthcare organizations gather to create "pathways"

EAST LANSING, MI – Area healthcare organizations gathered Wednesday to address one of their industry's most significant problems: re-hospitalizations. Patients and providers alike are often unprepared for the transition from one healthcare setting to another. That lack of coordination can lead to sudden readmissions to hospitals that cost billions of dollars a year. WKAR's Mark Bashore reports on a local effort to improve "care transitions" in mid-Michigan.

That's the sound of a patient being admitted to Lansing's Ingham Regional Medical Center. Some of those patients are re-admitted back to the hospital within days or weeks of their original discharge.

Experts say there's lots of room for improvement. Healthcare professional acknowledge that patients often leave hospitals unclear about follow-up care or medications. Data from the Centers for Medicaid and Medicare show over 16% of mid-Michigan beneficiaries are readmitted to the hospital within 30 days. That number jumps to 23% for people who have experienced heart failure. The numbers are even higher in other parts of the country.

Dr. Stephen Jencks is a leading national expert on care transitions. He says the transition from hospital care to the next stage is far from seamless.

"It's sort of like an astronaut going between space stations without a space suit," he says.

Jencks says it's crucial for patients to clarify specific information when they're first discharged from the hospital.

"One, the patient knows what medication to take and can get the medication," he adds. "Two, that they have a follow-up appointment and they know how to get to it, and three, what the signs of danger are, of deterioration are, and they who to call..."

But coordinating all of a single patient's caregivers can be an elusive goal. Dr. Dennis Perry oversees case management at Ingham Regional Medical Center.

"We've increased our quote-unquote efficiencies so when they go to the hospital, they're taken care of by a doctor that's never seen them before quite often," he says. "When they go to a nursing home, who has another doctor who hasn't seen them, and then maybe make it back to their family doc or internist who hasn't seen them for weeks or months. We need to sort of, go back, to some of the things we did before."

Another participant in the conference still takes part in a quaint practice of the past. Dr. Dan Fink is with the Visiting Physicians Association--a group of 130 doctors who specialize in house calls. The association serves 26,000 patients.

"They have oxygen tanks, you know. They're the housebound patients who can't access medical services without a taxing effort," he says. "So we can send in ahome healthcare team, a medical team, we can do all their testing at home. So then they're offered balance and stability rather than disaster and deterioration."

Health providers wrapped up Wednesday's conference in Lansing with a 'call to action'---a public pledge committing to the next phase of the Care Transitions collaborative. Next month, participants will spend time focusing on one of the most common causes of readmissions---heart failure. Group members say by 2011, they hope to have smoothed out a healthcare landscape that, by their own admission, is far too fragmented.