Pilot program aims to give patients support at home

Patients hospitalized for chronic illnesses often struggle after they are sent home, especially if they lack social support or money to manage their complex health needs.

So doctors are launching a pilot program at the University of Illinois Hospital and Health Sciences System that will use trained lay people to help these patients with follow-up visits, transportation, medication and questions related to their illnesses. The program aims to support recovery at home, thereby cutting down on the number of readmissions to hospitals, the doctors said.

Cutting readmissions is especially important because the federal Centers for Medicare and Medicaid Services have started to impose financial penalties on hospitals with high readmission rates, experts say.

Under the pilot program, patient navigators will visit hospitalized patients with heart failure, chronic obstructive pulmonary disease, pneumonia or sickle cell disease and follow them at home after they are discharged. Patient navigators will offer social support, helping with cooking, picking up prescriptions and coordinating health care, and working closely with family members, hospital social workers, doctors and nurses.

For emotional support, others who have experienced similar health challenges will counsel the patients by phone.

"Being in the hospital helps them recover from their illnesses. But nowadays, patients are not totally recovered and back to normal before they are discharged home," said Dr. Jerry Krishnan, an associate vice president of health affairs at the University of Illinois. Krishnan is leading the program.

"Not only do they now need to take care of themselves, but they're also going oftentimes in uncertain circumstances where they don't have all the help they need to get better," he said.

Krishnan said patients told the researchers in focus groups about their anxiety upon discharge and the social support they needed.

"The idea of navigators really embraces the ability of communities to help one another," said Krishnan, noting patients are often more comfortable talking to lay people than health care professionals.

Over the first year, the program will be tested on several dozen recently discharged individuals, and in the second and third years, on roughly a thousand patients.

Dr. Elizabeth Calhoun of the University of Illinois at Chicago and Mark Williams of Northwestern University are also working on the project.

Dr. Harold P. Freeman, a cancer surgeon who worked with patients in New York City's Harlem neighborhood for decades, came up with the idea of patient navigators as a way to help the many poor black breast cancer patients he treated who did not seek help until late in their disease. Patient navigators reduced the death rate of these patients from 70 percent to 39 percent, Freeman said.

"If you're poor, you have other survival priorities and experience other problems, such as lack of social support, poor housing, no transportation and less knowledge," said Freeman, founder and CEO of the Harold P. Freeman Patient Navigation Institute, which offers patient-navigation training.

Freeman said the Affordable Care Act next year will require that patient navigators be used to help an estimated 30 million uninsured people gain coverage.

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