Today, we begin a new feature on KHN, Letters to the Editor.

We welcome all comments and will publish as many as possible that are relevant. We will edit for space and require full names.

Joanne Lynn, M.D.
Director of Altarum Institute’s Center for Elder Care and Advanced Illness, which is researching and demonstrating new models to help an aging U.S. population live meaningfully and comfortably with serious chronic illnesses associated with advancing age, at a sustainable cost to our families and society.

Jordan Rau’s review of the upcoming Medicare push to make hospitals accountable for some of what happens to patients after discharge is a welcome counterpoint to the current drama over debt and spending. Congress mandated a number of penalties and incentives to force a certain amount of coordination between hospitals and post-hospital providers, and Medicare is moving along in implementing them. This work will improve care and reduce costs-a real win!

However, what we don’t often acknowledge is that a very important revision in how we conceive hospital care underlies these initiatives. Once, people in the community were presumed to be reasonably healthy. We sent people with tuberculosis or mental illness into institutions, and the period very near death was short. When you were suddenly very sick or needed a planned surgery, you went to the hospital and then recuperated and were well again. That was then and this is now. Our new way of living with illnesses makes it very likely that each of us will live for a substantial period with serious chronic illness. This is especially true for the time covered by Medicare or the veterans health care system. Old age or bad luck can hand you the opportunity to live longer than our grandparents imagined possible, but with substantial limitations, illnesses, and complications.

We have not redesigned our supports and health care to accommodate these new demographics. We still think of hospitalization as the start of an episode and hospital treatment as pursuit of a “cure,” whereas mostly people now have their health conditions before hospitalization and will still have them afterwards. Hospitalization has often become the “failure mode” in self-care and outpatient care. Having hospitalization become part of the overall plan of care has become an obviously correct reform-only we are not organized to do that. Hospitals, nursing homes, home care, hospice, and doctors are all paid separately in most of Medicare. They have little reason to cooperate for efficiency, and only their dedication to patient and family well-being provides a stimulus to pursue effectiveness. They have no structure available to integrate services, monitor performance, or set priorities. Indeed, health care providers mostly have never even met those who routinely provide care to their patients before or after their spell of service.

The aging of Baby Boomers is sure to strain our resources and our commitment to care for one another as needed. Building a care system that the community can sustain requires thinking, planning, measuring, and paying across traditional boundaries. Getting hospitals to pay attention to discharges and to how their communities can support sick and disabled people outside of the hospital is a bare start on what we will need to do.

Kimereng Kipsuge BSN, RN
Boise, Idaho

I think I will side with the hospitals in this one. I happen to work in a health care environment and am just giving my personal opinion. I do agree to some extent that we can help educate patients to make good choices in life. However, some patients will be non-compliant no matter how much information is given to them. Hospitals control in patient’s health is limited and therefore, should not be penalized for a patient’s re-admission times. Even though, Medicare/Medicaid intentions seem good, I foresee a situation where as hospitals adapt to the rules laid down by CMS, the overall quality of service/ health care may decline.

Patti Canterberry
Ellensburg, Wash.

I think that making sure patients are ready to be discharged will help. I also think that if the hospitals worked on their relationships with assisted living and nursing homes and the doctor offices as part of the continuum of care, it would help. We really can be a team that can work together. Using nurses and nurses practitioners thoughtfully is the key. I think that the medical community needs to take the leadership and put together systems that work for clients and their families.

Lynda S. Law
Jefferson, Colo.

What about the frequent flyers of the Emergency Departments? The homeless, alcoholics, drug seeking patients who often frequent the ED several times a month for their problems. These are not emergencies yet many people use the ED for their “habits” and their primary care because they either don’t have insurance, they don’t qualify for Medicaid and they just don’t care who pays for their care.

Trish Weaver R.N.,B.S., C.M

Readmission rates are quite complicated. Not all should be thought of as poor quality of care or a burden to the hospital. Some people don’t have a good discharge plan but they have a right to exercise their free will. As a result they are readmitted multiple times until they may agree to a plan that doesn’t include home. Some people are unable to pay for discharge medications or treatments or some just do not follow through for many reasons.

I know we can trim costs from Medicare and other insures by looking at end-of-life care. It isn’t popular but people do not understand what life or cure-at-any-cost means. We need to allow physicians time to talk to patients about what a [Do Not Resuscitat}e status means. It doesn’t mean we will not treat you. … I’ve witnessed so many people with long withdrawn hospital stays that are painful and costly to only end up finally withdrawing aggressive treatment after hundreds of thousands of dollars.

Janet Phelps-Zapata R.N. B.A.
Melbourne, Fla.

I was shocked to read the entire article on hospital re-admissions and not once was “Home Health Care” mentioned. We are the best resource the government has in keeping our fragile elderly safe, medically stable and at home. We are much more cost effective with lower rates of infection and better outcomes.

I would have to dispute that the hospitals are organized! We as home health providers have had to beg them to use our services to prevent re-admissions! We are always confused when we send a seriously ill patient to them and they are sent home.

Diana Lotz RN, BSN, OCN
Savannah, Ga.

This article disturbs me. The hospital cannot function as the hub for a patient’s managed care. We do set up follow-up appointments for patients with their doctors. We give them prescriptions and discuss side effects, we do try to get services set up for them, but we can only do so much. Patients have to be responsible too. They have to comply with follow-ups, take their medication and notify their doctor if they’re unable to take the medicine. Whoever is over at Medicare and came up with this ridiculous suggestion of the hospital being the primary healthcare overseer needs to wake up and get educated.