– From an article by John Murawski, Raleigh News and Observer

Juanita King, an 81-year-old grandmother, logged nearly five weeks at WakeMed Hospital since October after her breathing became so labored she had trouble walking.Weakened by a failing heart and obstructed lungs, she was at her Clayton home less than two weeks before returning to WakeMed for another round of needles, meds and tests.

WakeMed, along with hospitals across the country, is scrambling to keep patients like King from coming back. Under federal penalties that kicked in October 1 as part of the Patient Protection and Affordable Care Act, hospitals lose Medicare reimbursements if their patients are readmitted at an excessive rate. For example, WakeMed officials estimate that the 15 readmissions since 2010 that Medicare deemed excessive will cost the Raleigh health care company more than $400,000 in the coming year.

To ease the financial sting, hospitals increasingly are trying to manage patients’ health care after they are discharged. Hospital personnel make follow-up calls, schedule doctors’ visits and set up therapy appointments. Duke University Health System is planning to offer apps designed to send prompts and reminders for patients to take meds and report symptoms.

Hospital administrators say the pressure to reduce readmissions is forcing them to take long overdue steps by coordinating with nursing homes and family caretakers to treat health problems early, before they blow up into emergencies.

King saw a difference at Wake-Med on her return visit. “This time it was more focused, it seemed to me. The cardiac and respiratory team was working together. They apparently identified what my needs were.”

The penalties in the federal health care law are designed to reduce unnecessary costs and curb waste. Chronically ill, elderly patients, typically on a fixed income, are among the costliest in the system. Some rotate in and out of emergency rooms as a way of dealing with poor health.

Medicare’s negative reinforcement is already showing results and reducing readmission rates among Triangle hospitals; administrators say patients are better off on account of the follow-ups, monitoring and early intervention.

The maximum Medicare penalty this year for excessive readmissions is a one percent reduction in Medicare reimbursements. The fine will increase to three percent in 2015, which can translate to millions of dollars in lost revenue for a hospital.

Patients often go back into a hospital because they have trouble following directions for their medications. During a hospital stay and while recuperating, patients can be disoriented and confused, making it hard to keep track of multiple medications. Heart patients, for example, are urged to adhere to a low sodium diet, but not all comply. “We had one patient who was taking their pills with pickle juice,” said Linda Butler, chief medical officer at Rex Healthcare in Raleigh.

In the Triangle, Rex Hospital was penalized 0.16 percent, UNC Hospital 0.23 percent, WakeMed 0.29 percent and Duke University Hospital 0.47 percent. Duke’s penalty, the highest in the Triangle, will cost the system about $600,000 in reduced Medicare reimbursements from the federal government, said Thomas Owens, chief medical officer at the Duke University Health System.

Owens noted that the penalty patterns in the Triangle reflect the type of patient each hospital treats. Duke hospital draws heart-transplant and lung-transplant patients from a broad region, and the Durham facility can be penalized if any of its patients are readmitted for any reason to other hospitals.

Rex runs a readmission prevention clinic two days a week where dietitians, clinical nurses and pharmacists coach recently discharged patients on staying healthy. Rex’s Medicare penalty, for six readmissions too many, will cost the Raleigh hospital an estimated $80,000.

Through various strategies, WakeMed has cut readmissions by about five percent this year. The health care company has compiled details on services offered by more than a dozen area nursing homes, referring to its “grid” when deciding where to send patients after discharge.

“It’s basically sharing information which in the past has never been shared,” said Christy Henry, medical director of case and clinical resource management at Rex. “In the past, no one really knew what the nursing homes could provide.”