What's the best way to improve the lives of people with chronic diseases?
Sometimes, it's simply doing the little things that help them stay out of a hospital bed.
Diana Bradley lives with kidney failure, high blood pressure and diabetes that led to a lower leg amputation. Yet, while watching television in her north Columbia apartment recently, she smiled and said, "I'm doing good."
Compared with six months ago, she's doing great. Back then, she would stay overnight in the hospital for a few days, go home for a few weeks, then check back in the hospital. "I was going so regular I thought it was my home," said Bradley, 66.
Doctors set up appointments for her dialysis treatments, but she was scared to go. Finally, the Ambulatory Care Transition team at Palmetto Health Richland got through to her. A nurse and a social worker talked with her in the hospital, then came to her house to coach her through the confusing gauntlet that is Medicare and Medicaid.
They also made her comfortable with the medical procedures ahead. Now, a bus picks her up three times a week, takes her to dialysis and brings her home. The Palmetto Health team checks in routinely, and church members overwhelm her with food.
The end result: Bradley hasn't had to stay overnight in a hospital in five months.
That's good for her mood. And it's good for anyone else who ever will rely on Medicare. A 2006 study by transitions guru Dr. Eric Coleman of the University of Colorado estimated one in-home coach cut the health care costs of 379 patients by nearly $300,000 in a year.
The move to transition in-home care took off recently when the Affordable Care Act began fining hospitals if patients with certain chronic illnesses are re-hospitalized within 30 days. The 30-day readmissions fines might not get the publicity of the Affordable Care Act's insurance mandates, but hospitals' reactions to the fines eventually could impact just about anyone who doesn't die suddenly.
At least 50 hospitals in South Carolina have begun expanding their reach into the homes of chronic illness patients, according to the S.C. Partnership for Health, which is fostering many of the efforts. Some partner with outside groups, like Providence Hospital's program featured July 14 in The State. Some use their own employees, like Palmetto Health. The programs offer a variety of assistance, ranging from setting up doctor's appointments to helping pick out groceries suitable for special diets.
Palmetto Health's Ambulatory Care Transition team has worked with 400 patients since August 2010, and only about 5 percent have been readmitted within 30 days. The national average is 25 percent.
The reason for the success is simple, according to team manager Jennifer Porth.
"We're developing a relationship that nobody in the health care system has developed before," Porth said. The forms to fill out and hurdles to clear "are complicated enough, then you throw life into it. We help them take baby steps (in those first weeks out of the hospital) while they have support. What better time to screw up than when you have a safety net?"
The support teams even resort to psychological ploys. One patient with swollen feet from congestive heart failure kept forgetting to take her medication, Porth said. The team finally got through to her when they found out she wanted to walk down the aisle at her daughter's wedding.
"It truly became, 'If I want to walk down the aisle, I need to take my Lasix,'" Porth said.
The patient did walk down that aisle. Her transition team even went above and beyond by helping her pick out the right dress. ___[Image by flicker user jason parreira]