Will they be back? Predicting readmissions for elderly patients

Seniors living in the most disadvantaged 15 percent of U.S. neighborhoods are much more likely to make repeat trips to the hospital, according to a study by Amy Kind, a University of Wisconsin–Madison assistant professor of medicine.

Stopping that trend would save Medicare billions, and Kind has developed a tool to give doctors and nurses a head start.

Each year about 2.6 million Medicare patients are readmitted to the hospital within a month, costing the government more than $26 billion. The Affordable Care Act will begin penalizing hospitals where seniors are readmitted within this time frame, giving them incentive to try Kind’s tool, which links the patient’s extended ZIP code to an area disadvantage scale.

Kind, a geriatrics specialist who practices at the William S. Middleton VA Hospital, says she hopes that checking a patient’s neighborhood demographics will be the beginning of a conversation between clinician and patient.

“It should alert them to ask whether the patient has access to healthy food, transportation and supportive care,” she says, adding that demographic information could also help policymakers know where to target more resources.

The set on neighborhood disadvantage and Medicare readmissions was downloaded at least 59 times in the first two weeks since it went online this December. Organizations that downloaded the toolkit in its first two weeks include:

• Centers for Medicare & Medicaid Innovation
• New York State Department of Health
• Wisconsin Department of Health Services
• Several health systems and hospitals, such as Brigham and Women’s Hospital and Massachusetts General Hospital
• Several universities, including Harvard Medical School, Johns Hopkins Bloomberg School of Public Health, Vanderbilt University, and others

The online zip code tool — which helps doctors and nurses quickly predict which elderly patients live in neighborhoods where they may not get adequate support — was accessed another 198 times.