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As lawmakers attempt to ease pressure on Americas health care system, here's a number they might consider. When older patients are discharged from a hospital, one out of five will come right back within a month. Medicare pays $17 billion a year on these hospital readmissions. NPRs Joseph Shapiro explains that in many cases, return visits should have been avoidable.

JOSEPH SHAPIRO: So its kind of a no brainer. If you can keep people from returning to the hospital, you get patients who are healthier, government and private insurers save money. But the way our health care system is set up encourages all this waste and the bad health outcomes, too.

Ms. JESSICA MACLEOD (Nurse, University of Pennsylvania): Could I get a listen to your ticker?

Mr. KEN ROGERS (Retired): Sure.

Ms. MACLEOD: Let me get a good listen.

SHAPIRO: Jessica MACLEOD is trying to change that.

Ms. MACLEOD: So now shortness of breath? No chest pains? No palpitations, you told me.

SHAPIRO: MACLEOD is a young nurse with the University of Pennsylvania. On this day, shes driven her worn down Corolla to the Philadelphia home of Ken Rogers. Hes 80, a retired printer, who spent the week in the hospital with chest pains. Today, MACLEOD is checking him out in the sunroom of his tidy brick home, overlooking the patch of red gardenias, roses and the other flowers he grows.

Ms. MACLEOD: I saw your weight, so thats looking good. Dizziness, light headedness? None at all?

SHAPIRO: MACLEOD first met Rogers when he was in the hospital last month. She came to see him every day he was there for a week. Then when he left the hospital she was at his home in the first 24 hours. She makes these home visits once a week.

Ms. MACLEOD: Ill meet up with you at Dr. Carvers, the cardiologist appointment. All right?

SHAPIRO: And she goes with Rogers and his wife Peg when hes got a doctors appointment.

Ms. MACLEOD: Does that sound reasonable to you guys?

Mr. ROGERS: Yes.

Ms. MACLEOD: Ok.

Ms. PEG ROGERS: I have one question.

Ms. MACLEOD: Yes.

Ms. ROGERS: Something I don't understand. This atrial fibrillation. Ok. Hes had this pacemaker now for several years. Everythings been fine until after his surgery. So would that have caused it?

SHAPIRO: MACLEOD spent about an hour on this home visit. Its kind of like having a good friend come over and hang out, only this friend knows everything about medicine.

Ms. MACLEOD: So, so many things can cause atrial fibrillation, and I am not sure what caused your A-Fib. So an illness, an infection can cause it. Some medications can cause it.

SHAPIRO: MacLeod explains that if she can help Ken Rogers manage his care, then the chances are pretty good he wont have an avoidable readmission to the hospital. This makes a lot of sense to Rogers. Its not the way things worked when hes been in the hospital in the past.

Mr. ROGERS: Usually when - before this when I came out of the hospital, you go, yeah? What do I do now?

Ms. MACLEOD: Yeah.

Mr. ROGERS: You know what I mean?

Ms. MACLEOD: Yeah.

Mr. ROGERS: It was (kissing sound) see ya.

SHAPIRO: At the end of the visit, MacLeod gets back in her car.

Ms. MACLEOD: Mr. and Mrs. Rogers I would consider very smart and savvy people, and assertive. And even having those skills, health care is complex, and we have a health care system that is increasingly complicated. And, you know, if you've ever been to the doctor's office yourself, you are hearing words for the first time, and they're maybe said once. And it's hard to get a word in edgewise sometimes and say, wait, what is atrial fibrillation, doc? You know, what does that mean? So part of my job is a translator, really, and I translate the language of health care to a lay person's language.

SHAPIRO: MacLeod does this work for a program at the University of Pennsylvania health system called the Transitional Care Model.

Professor MARY NAYLOR (Nursing, University of Pennsylvania): Its about relationships.

SHAPIRO: Mary Naylor started the program. Shes a professor of nursing at the University of Pennsylvania.

Professor NAYLOR: The same nurse who begins to work with the patient in the hospital, they become the point person. They become a broker of care for these individuals over time. They only leave them when they think that Mr. Smith or Mrs. Jones is no longer at risk for a poor outcome.

SHAPIRO: A nurse, usually a nurse practitioner, follows a patient for about three months after a hospital stay. Its not cheap to do this, but Naylors studies show the program saves about $5,000 a year for each Medicare patient, largely by keeping them from going back into the hospital. But Medicare doesnt pay for the nurse practitioners. And hospitals make the most money when people go into the hospital, not when theyre kept out.

Dr. Stephen Jencks is a researcher and former Medicare official who's studied the issue. He says that it's time to change the health care system and start paying upfront to coordinate care.

Dr. STEPHEN JENCKS (Researcher): We are not in a business where we should have to be accepting this choice that we're either going to have to cut the care we give or we're going to have to accept higher bills. There's a third way of doing it, which is redesigning the care so that we do the things that people want that are effective and that cost less than doing it wrong.

SHAPIRO: It was Jencks study - published earlier this year - that came up with those stunning numbers: one out of five Medicare patients go back into the hospital in a month at a cost of about $17 billion a year. Jencks thinks the readmission rate could easily could be cut by 15 percent, and with harder work, maybe even in half.

Dr. JENCKS: Almost anybody can see that if you can keep the patient healthy, the patient is better off and Medicare is better off, and you're delivering the kind of care most people would want to have: win, win, win.

SHAPIRO: And thats why the issue has gotten the attention of the Obama administration and of policy makers trying to change health care.

Joseph Shapiro, NPR News.

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