Everything Old Is New Again...

I spent a good part of the afternoon listening to a webinar (I can't get streaming video on my work laptop - an I.T. Control Issue) about Transitional Care to Prevent Readmission to the Hospital.

Now readmissions to hospitals are going to be a big deal soon - for hospitals. If CMS (the people who run Medicare and Medicaid) think the patient was readmitted too soon (God forbid they're really sick), then Medicare may not cover the cost of that second readmission. That's a bit simplified but it's basically what may happen. And I was listening to the webinar because that may filter down to nursing homes. If the hospitals don't want the resident back because of a too early readmit, then we have to take care of them. Who gets lost in all of this - well, the patient.

Anyway this high-falooting Transitional Care thingy....actually they're various processes developed by various high-falooting organizations paid for by the above CMS and staffed with people with lots of letters after their names, using high-falooting terms like "evidence based knowledge", "improved transitions of beneficiaries", and (my favorite) "range of time-limited services that complement primary care...:"

What the entire webinar was about was helping people being discharged from the hospital to care for themselves at home.

This is what I did thirty years ago as the Visiting Nurse Association's Liaison Nurse to the hospital. I would visit patients and talk to them about their home care, set up their Care Plans and call the information into the VNA's office. The nurse and/or social worker would visit that day or the day after. Because the VNA received money from the communities and the United Way, nurses even made well-baby visits to first-time mothers and their newborns.

What happened to all of that? Well, if I remember correctly (I wasn't there when it happened - thank goodness), the VNA was absorbed by the hospital which was bought by a for-profit corporation which then eliminated most of the "Transitional Care" part.

Aha!

So it seems that thirty years ago we had the right idea....
Too bad, we now to pay for the organizations staffed with lots of people with lots of degrees to tell us this, when it was once all there - with nurses...