The announcement of the annual MacArthur Foundation Fellowships, aka "the genius grants," always shines a light on some of the most creative and important thinking being done in the United States. This year's 23 recipients, each of whom has been awarded a no-strings-attached $500,000 fellowship paid out over five years, include a novelist, a mathematician, an astronomer, a mandolinist, and a geriatrician whose vision is to reduce hospital readmissions among elderly patients, in part by empowering family caregivers. His work could save the nation's health-care system millions of dollars.
Dr. Eric Coleman, 47, of the University of Colorado School of Medicine, has spent more than 20 years examining the problem of hospital "handoffs" for older patients, a crucial challenge for the health-care system and for family caregivers. A recent study co-authored by Coleman and published in the New England Journal of Medicine found that about 20 percent of Medicare recipients end up back in the hospital within 30 days of discharge. The causes are largely poor communication from doctors and nurses about follow-up care, and patients' and caregivers' poor management of medication and therapy regimens. Coleman has described the post-discharge experience for patients as a "drive-by shooting." In 2004 his team estimated that the cost to Medicare of such "unplanned rehospitalizations" was $17.4 billion.
To combat the problem, Coleman developed the Care Transitions Program, which is intended to improve care during the handoff from hospital to home or nursing home. So far the strategies have been shown to reduce hospital readmissions by 20 to 50 percent where they have been adopted and tested. As Coleman's team wrote in the journal article, "a safe transition from a hospital to the community or a nursing home requires care that centers on the patient and transcends organizational boundaries."
During the four-week Care Transitions Program, a trained "transitions coach" helps patients with complex care needs learn self-management so they can successfully reacclimatize themselves to their homes, and to whatever new treatments they require. The program also includes tools and training for family caregivers; Coleman has called them "a silent partner in health care delivery, functioning as de facto care coordinators."
The success of Care Transitions has already been recognized by the federal government, which committed $500 million over five years to support community-based groups working to improve hospital handoffs for Medicare patients, as part of the Affordable Care Act. Many of those local groups follow Coleman's Care Transitions model.
"The key to improving the quality of care transitions is to reaffirm a commitment to person-centered care that remains notably absent in how we typically design and deliver health care," Coleman said in a recent interview with the Commonwealth Fund. "We strive to help the patient move from the back seat to the passenger's seat to the driver's seat in assuming a more assertive role in managing their condition and their transitions.
"We know from principles of adult learning that patients learn best from simulation or practicing these newly acquired skills and from having the opportunity to also make mistakes and learn from mistakes. Under the current delivery system, health professionals tend to do things for patients — which is analogous to giving a person a fish. To produce a more sustained benefit, we are attempting to teach patients to fish."