The costs associated with hospital readmission for recently discharged patients manifest themselves in many ways. It costs the hospital in resource allocation and in real dollars, particularly for the growing number of facilities that take capitated risk, participate in an accountable care organization or partner in their own health plan. It costs the government meaningful dollars (that otherwise could have been redirected toward other health care needs) in reimbursing for the costs for Medicare or Medicaid beneficiaries who are commonly the highest sources of readmission. And it costs the patient and family emotional burden by taking them out of the comfort of their own home and subjecting them to the trauma, costs, anxieties and inconvenience that come with hospitalization.

Given our aging society and the many demands for limited health care dollars, finding ways to reduce readmissions is more critical than ever. It is no wonder that hospital leaders across the country are paying closer attention to what happens to patients (particularly seniors) after they're discharged.

Readmission Prevention Programs

A full array of complex, care management programs attempt to stem the flow of readmissions. Each takes a different approach to optimizing the health and well-being of the discharged patient. One side of the spectrum consists of medical interventions with registered nurses leading the care management team, while the opposite end features case management and navigation, rather than medical care, with social workers as leaders.

One solution that is beginning to gain noticeable traction is a kind of hybrid between these two approaches; it involves a high-intensity, care-team approach outside of the hospital setting. Going far beyond traditional care coordination or transition planning, such an approach intentionally addresses common geriatric conditions (e.g., falls, depression and memory problems), proactive care management, patient education, health assessment, monitoring and counseling. As documented in a 2014 Avalere Health study, this kind of approach can enhance quality of care in ways that optimize health and functional status; decrease excess health care use; prevent long-term nursing home placement; and, most importantly, substantially reduce emergency department visits and hospitalizations.

The key to such a program is a unique and specially trained support team headed by both a nurse practitioner and a social worker who, in tandem, support the primary care physician in fully addressing a patient's health conditions and achieving a patient's goal from the comfort of his or her own home. Beginning at the time of hospital discharge, the team works closely with the staff at the ED or hospital to optimize care transition. During the transition, they collaborate with the hospital discharge planners, support the patient and their family or caregiver, make a post-discharge home visit where medications are reconciled, ensure that services such as home health care are implemented as planned, and coordinate with home and community-based long-term services.

With the support of an electronic health record and a longitudinal tracking system, this team provides patients with specialized care for geriatric conditions; medication management; and coordination of care among specialty physicians, the ED, hospitals and a broad array of community support services.

Central to this approach is a strong emphasis on health care education that includes teaching patients about their diseases and learning how to recognize symptoms, along with the importance of adherence to diet, exercise and medication regimens. It also involves close interaction with community agencies and independent resources to make sure that patients have the tools and support they need to succeed. This type of high-intensity care coordination can deliver proven value: It optimizes health and functional status, and decreases excess health care use in ways that result in lower overall health care costs.

Such coordination and individualization of the care management approach is in stark contrast to the fragmented, incomplete, inefficient and ineffective care that many older patients — the most vulnerable among us — often receive. And the results are worth noting. As they are implemented in select markets around the country, programs such as this have shown to reduce by 50 percent the 30-day readmission rate in high-risk patients. It is proving to be especially effective in addressing the health care needs of low-income seniors, dual eligibles and others with complex medical and social needs.

The Benefits of a Hybrid Program

In addition to reducing hospital readmissions, such a program can bring two other measurable values to a hospital. First, it can reduce hospital length of stay because physicians, including hospitalists, are more comfortable sending a patient home sooner (or to home instead of a skilled nursing facility) if they are confident that such intense post-acute care coordination is in place. For the hospitalist specifically, this program can improve job satisfaction and performance by helping to provide baseline information on the patient (home support, medications, baseline cognitive and functional status, community services, caregiver, physicians, etc.) and help with planning the transition from hospital to home.

Second, this type of program can be of significant value as the industry moves from fee for service to value-based pricing. Here the Centers for Medicare & Medicaid Services, under its Five-Star Quality Rating System, rewards acute care hospitals with incentive payments for the quality of care they provide to people with Medicare. Incentives cover such factors as how closely best clinical practices are followed, how well hospitals enhance the patient experience and to what extent institutions have programs in place specifically aimed at reducing readmissions. Beyond CMS, self-insured employers and other payers increasingly are looking at dashboards in making their provider selections.

Needs for an Aging Society

As America ages, there appears to be universal agreement that all participants in the health care equation — hospitals, physicians, health plans, government regulators and others — need to find new ways to care for a society that will see more than 70 million of its citizens turn 65 or older by 2030 (double what it is today). Providing exceptional, patient-focused care in the hospital is a good start. But it is not the stand-alone answer, and relying solely on care in the acute care setting is an untenable position.

Instead, inpatient care must be complemented by an effective program outside of the hospital setting where resources can be properly allocated, patient needs and preferences can be addressed, and care can be delivered in the most appropriate and cost-effective setting. Hospitals have a vital interest in making this a reality as such programs can reduce readmissions, decrease lengths of stay and help to set the tone for a value-driven system of care. And, with that, everyone wins.

Steven Counsell, M.D., is the executive director of the GRACE Team Care program, Mary Elizabeth Mitchell professor of geriatric medicine, and director of the geriatrics program at Indiana University School of Medicine, Indianapolis. He is also president-elect of the American Geriatrics Society.