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Helping seniors reduce unnecessary hospital visits

POSTED March 9, 2018 6:39 p.m.

Hospitalizations for seniors can be devastating, both financially and emotionally. But what’s worse is having to return to the hospital shortly after discharge – especially if the readmission could have been prevented.

All too often, this is precisely what happens: Roughly one in five Medicare patients discharged from the hospital ends up being readmitted within 30 days, at a cost to the federal government of $26 billion per year. The Medicare Payment Advisory Committee estimates up to 75 percent of these readmissions could have been prevented.

So what’s going on? Protecting seniors from avoidable readmissions to local hospitals is difficult. Far too often, hospitals discharge Medicare patients quickly to ensure that the hospital is not penalized by the federal government. The Medicare patient may receive home health services following the hospital discharge, but for a limited period. Often, the patient needs more care, but Medicare refuses to pay for it. In the end, the patient re-appears at the hospital emergency department because a transitional care program did not exist.

The impact on the senior cannot be measured in dollars and cents: far too often, their lives are devastated when re-hospitalized. Compounding the problem is the fact that fewer than 50 percent of patients see their primary care providers within two weeks of hospital discharge -- assuming they even have one.

The good news is that this can be fixed. The bad news is that Congress and state legislators aren’t making those fixes. If we hope to solve this problem, we’ll need to do so at the local or regional level. Legacy Health Endowment and Covenant Care at Home and Hospice have begun to do so.

Together, these organizations are launching a program, Transitional Care for Seniors (TCS), that provides targeted Medicare recipients with the care needed to ensure against the fear of rehospitalization, or worse, placement into a nursing home. The TCS program is designed to ensure coordination and continuity of health care as the Medicare patient transitions from hospital to home. The goal is simple: prevent healthcare complications and re-hospitalizations of seniors who are at high risk for readmission and who may experience one or more of the following conditions:

· Heart Failure

· Multiple admissions

· Multiple falls in the home or a fall with injury

· Lack of a primary care physician

The program is limited to people who fall into these categories because they present the greatest risk of re-entering the hospital. The senior would be eligible for assistance with a personal care aid, up to 10 hours of private duty nursing. This care can be implemented the first few hours after discharge when the senior is most vulnerable to falls and when Home Health has ended. There is no charge for the TCS program; charitable dollars are being used to ensure that people in need obtain the care necessary to help them stay in their homes. TCS is providing refuge from a healthcare system that failed them by ending services too soon.

America is long overdue in helping seniors avoid the fear of re-entering a hospital because services are not available. The TCS program illustrates how real solutions can be created in local communities.

Initially, this program will focus on patients suffering from heart failure. More than 6 million people in the U.S. suffer from heart failure, with approximately 800,000 new cases diagnosed each year. Research tells us that readmissions for heart failure patients, including those visiting hospital emergency departments, can be prevented through programs like TCS. Over time, we will update the communities across California and the nation on the positive impact of this program, the money saved and the lives helped.

The program will be available to people living within the Greater LHE Community, which covers 19 ZIP codes in Southern Stanislaus County and Merced County, including the communities of West Modesto, Ceres, Turlock, Newman, Patterson, Crows Landing, Hughson, Keyes, Gustine, Newman, Hilmar, Livingston, Stevinson, Atwater, Denair, Winton, Ballico and Delhi.

This is how philanthropy can be used as venture capital – reinvesting in communities and the people living there. Changing healthcare often amounts to one step at a time, building dignity back into the lives of seniors with grace and compassion

— Jeffrey Lewis is the President and CEO of Legacy Health Endowment that was created from the sale of Emanuel Medical Center to Doctors Hospital of Modesto. He can be reached at


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