Coordinated Effort

Readmission to hospitals is a national problem. Grace Jenq, MD

Grace Jenq, MD, has dedicated much of her career to caring for elderly patients. Nonetheless, these days she’s working hard to avoid seeing them in the hospital—or at least seeing them again.

Jenq, who specializes in geriatric medicine, is the lead physician in YNHH’s participation in a two-year federal program, tied into the Affordable Care Act, designed to reduce the high rate of hospital readmissions among a select group of elderly Medicare patients living in the Greater New Haven area. Yale-New Haven is a partner in the program, with the Agency on Aging of South Central Connecticut (AASCC).

“Readmission is a national problem,” Jenq reports, “with one out of five Medicare patients readmitted to the hospital within 30 days.” The federal government estimates that Medicare spends nearly $17 billion a year on readmissions.

The focused geriatric program at YNHH has enrolled hundreds of elderly Medicare inpatients who have been determined to be most vulnerable for readmission. Each patient is assigned a care coordinator, a specially trained registered nurse whose interaction begins during the initial assessment process. “We screen the patient to look for factors that would predispose him or her for readmission,” says Lynn Triebel, RN, one of several care coordinators in the program. Often coordinating with the family, she determines the patient’s medical condition and history, post-discharge treatment plan, medications, follow-up appointments and whether he’ll be going home or to another care facility.

“If the patient is going home, I’m responsible for assessing her needs and arranging for homecare services and/or equipment such as a walker, a hospital bed or oxygen,” Triebel says. “If she has to go to another facility, we help find the right place.”

Triebel simultaneously refers her patients to social workers at AASCC, who assist them in accessing appropriate community resources and services outside the hospital, such as adult day care, hospice, senior housing, Meals on Wheels and transportation. Patients are then tracked to ensure that all the elements of their transition are in place and going smoothly.

The results of this innovative geriatric program are being closely monitored. “We have to show a 20 percent reduction in our patients’ readmissions in order for us to renew it for another three years,” says Jenq, who points to the dual goals of the program. “As much as we can improve safe transitions for our elderly patients, our mission also is to lower health care costs.”