Bill would help patients, caregivers transitioning from hospital to home care

June 17, 2009

(Washington, DC) - U.S. Senators Jeanne Shaheen (D-NH) and Susan Collins (R-ME) today held a press conference call to discuss the bipartisan Medicare Transitional Care Act, which would help ensure that appropriate follow-up care is provided for seniors who are discharged from a hospital, thus preventing unnecessary re-hospitalization.  A New England Journal of Medicine study conducted earlier this year found that almost one-third of Medicare patients who were discharged from a hospital were re-hospitalized within 90 days largely due to lack of follow-up care, unnecessarily driving-up health care costs.  Shaheen and Collins will formally introduce the legislation tomorrow.

"Sending healthy patients home to manage their care is important, but we need to make sure they are prepared to manage their conditions and medications so that they don't end up back in the hospital a few weeks later," said Senator Shaheen.  "Unnecessary re-hospitalization is costly for our government and troublesome for our seniors.  But it's also avoidable, and this legislation will help make sure the transition from hospital to home care is managed appropriately, which would improve the quality of care for our seniors and reduce our nation's health care costs."

"Transitions from hospital to home can be complicated, particularly for older individuals with multiple chronic conditions.  In Maine, nearly 20 percent of Medicare patients who are discharged from the hospital are readmitted within thirty days," said Senator Collins.  "The legislation that Senator Shaheen and I are introducing will help Medicare patients make the transition from hospital to home safely.  Moreover, it will not only improve the quality of patient care, but it will also save Medicare money by preventing these costly and unnecessary hospital readmissions."

Research shows that the transition from the hospital to the patient's next place of care (home, nursing facilities, rehabilitation centers, etc.) can be complicated and involves health risk.  Older patients, particularly those with multiple chronic conditions, often admit difficulty remembering instructions, confusion over correct use of medications, and general uncertainty about their condition.  The Medicare Transitional Care Act would provide these patients the support and assistance they need to manage their health needs with their caregivers.

"The transition from hospital to home is not always an easy one and can be fraught with problems," said Margaret Franckhauser, Executive Director of Community Health & Hospice in Laconia, New Hampshire, who joined the Senators on the call.  "For those with multiple chronic conditions in particular or other risk factors, a single misstep in the transition of care can result in serious complications and readmission to the hospital."


This legislation would also create significant cost savings.  Medicare spent an estimated $17.4 billion in 2004 on unplanned re-hospitalizations.  Experts estimate this legislation could save up to $5,000 per Medicare beneficiary.

Under the Medicare Transitional Care Act, a qualified transitional care clinician would ensure that appropriate follow-up care is provided during the vulnerable time patients face after discharge from a hospital.  The benefit would be phased-in and provided first for the most at-risk individuals, such as those with multiple chronic conditions.  Services provided may include instructions for patients and caregivers on how and when to take or administer medication; help scheduling and getting to follow-up appointments with doctors; and help coordinating support services, such as meal delivery, transportation, and assistance with other daily activities.

"It's unacceptable that 20 percent of people in Medicare who visit the hospital will return within a month, often because they aren't getting the follow-up care they need," said AARP Executive Vice President Nancy LeaMond.  "We're sending home too many people with a handful of prescriptions and no support.  Something as simple as help to set up a medication schedule could be the difference between getting healthy or winding up back in a hospital bed."

Representatives Earl Blumenauer (D-OR) and Charles Boustany (R-LA) introduced companion legislation in the U.S. House of Representatives last week.  The Medicare Transitional Care Act has been co-sponsored in the Senate by Senator Blanche Lincoln (D-AR).  The legislation has also been endorsed by AARP.

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Alex Reese