Numerous recent articles such as How to Bypass the Revolving Door (http://newoldage.blogs.nytimes.com/2012/11/02/how-to-bypass-the-revolving-door/) and Shutting the Revolving Door discuss how Hospitals are attempting to lower readmission rates. The theory behind penalties for readmissions is that doing things differently during the first admission will lead to fewer readmissions. "Best Practices" have been developed to accomplish that.

However, a recent large study of Medicare recipients concluded "Hospitals with greater adherence to recommended care processes did not achieve meaningfully better 30-day hospital readmission rates" (Hospital Performance Measures and 30-day Readmission Rates Stefan, MS et al J Gen Intern Med, October 16, 1012) Readmissions are a part of the much larger issue of how to manage people with chronic conditions that will not get significantly better. This issue manifests itself in several facets of care delivery.

Jimmo v. Sebelius.[1], the "Improvement Standard" case, decided this year, in which Medicare agreed to drop the criterion that treatment must be expected to result in improvement in order to be covered is one example. It can now be covered if that treatment is required to maintain the patient's condition.

 Another is the rapidly increasing practice of "observing" patients in hospitals rather than admitting them. "Observed" patients don't fall into the readmission criteria. These patients are sent home within prescribed time limits, often without having received much care. Unfortunately, if they are "observed" they may not be eligible for transfer to a transitional care facility. Sometimes the client finds that out when they receive a very large bill from the transitional facility. Sometimes they just return home, where support may be inadequate.

As the population ages, we will have more people with multiple chronic conditions. Often these people have a prolonged course with frequent exacerbations and little real improvement of the underlying conditions during a hospital admission. As an example, although an admission may be required to treat pneumonia, the patient will still have congestive heart failure and COPD when they leave. Hospitals are acute care organizations. Even with the best hospital treatment, many of the chronically ill will be readmitted in a short period of time.

Nevertheless, there is pressure to keep admissions short and now to develop ways to prevent re-admission. Hospitals' immediate concern is that Medicare has introduced penalties for hospitals that have "too many" readmissions within 30 days.   "In Massachusetts, 54 medical centers will lose some money", according to the Globe article.Many hospitals and vendors have developed programs to avoid those re-admissions. Unfortunately, they sometimes result in serious demands on sick seniors and their families.

Focusing on readmissions often results in problems in other facets of care. The length of stay and re-admission issues are not really germane to good care. These are remuneration struggles between providers and payers. The cost of an empty hospital bed is very high, as is the cost of a re-admission, and the incremental cost of keeping someone in that bed for an extra day to get a little stronger is not. In many cases it would make sense to keep the complex patient a little longer.

Programs now exist to assist frail patients to get home from the hospital and get resettled. They are offered by a multitude of vendors. Some are as short as 3 hours. Some follow the patient for 30 days. Although they may provide some assistance, we believe the shorter programs are unlikely to provide much benefit, or significantly reduce readmissions. They provide another link in the fragmented care seniors receive. If they result in the senior getting help over a longer period, they may be useful. The longer programs may achieve their goal, and hopefully will allow the senior and the caregivers to begin to know each other.

Ultimately, we believe that in this case, as in most issues involving seniors, everyone would benefit from realizing that aging is a stage of life, not a sickness, and that the best support is ongoing. Jimmo vs. Sebelius is a recognition of that. We hope that access to support for seniors will be expanded as rapidly as possible.

Seniors and families should plan well ahead of a medical crisis. They should get help as soon as it is needed. Prevention of a crisis such as a fall or complications due to skipping medicines or inadequate nutrition or simply isolation and inactivity is usually considerably less expensive than providing support after a crisis. The adage that an ounce of prevention is worth a pound of cure is certainly true here.