One in five Medicare hospital departures result in a readmission within a month -- says this Remington Report -- which describes a new Medicare program to monitor transitions in care (including a web-based tracking tool for updates on care status) and as a program to help with these transitions, CMS itself will be monitoring readmission rates at a macro level for the participating communities, selected from across the country. 

Tools for Medicare providers. For providers within discharging hospitals, they now have a tool with standardized data elements for tracking status of care transitions after hospital discharge. They can use this to track the readmission rate over all. Nice tools -- that with complete training and diligent use, providers should be able to assess over time and in retrospect how well the people-based quality improvement programs (QIO) are working.

No tools for monitoring in the home. This concept, however, does not directly address the readmission problem or the quality of life of the patient, now a person in the home. No even small scale technology is proposed here to help the individual who has left the hospital to better manage their condition themselves or with the help of a family member.  Aren't there home health technologies -- medication reminders, sensor-based home monitoring, device-based person monitoring, disease status monitoring that could be usd to augment the front and the back end of this cycle? Do the providers know about and promote the use of these technology categories?*

No tools to help a person live better at home. Finally, where is the mention of technology to help manage and function more effectively in their daily lives. Because after all, once released from the hospital or rehab -- and back in the home, this is a senior's best shot at re-engaging with their life. Who is calling them regularly on the phone? Could they have a simple videophone for providers to look at them face-to-face when asking how they're doing? Are they or their caregiver/family member able to help them learn about others with the same illness?

VA has solved this problem while CMS is fiddling.  The Veterans Administration has already and without a doubt confirmed that use of home-based technologies reduces hospital stays by 25%, readmissions by 19%, and resulted in higher satisfaction among participants. And they list the categories: videophones, messaging devices, biometric devices, digital cameras and telemonitoring devices.  No before-after reporting tools can substitute for application of the same level of technology investment to improving the actual life of a person who has returned home from the hospital. We could quibble about which vendors of which products, but here are some examples.

 * Medication reminders: OnTimeRX, Medication-Reminders.com, Philips CarePartner Telephone with reminders

   Medication dispensers: Philips MD-2, Autopills, Med-Ready

   Monitoring home: Grandcare, QuietCare, Healthsense

   Monitoring the person:  HaloMonitoring, LifeAlert, Philips Lifeline

   Monitor the disease: ZumeLife, PatientsLikeMe, Intel Health Guide

   Videophone: Vidtel, D-Link, PC camera with Skype

For those healthcare professionals involved in these programs within the nominated geographies, become educated in these technologies, then consider allocating some of the funds to in-the-home technology that helps avoid readmission, and also helps them engage in life.