Herman Rockman sits in a comfortable wing chair in the living room of his West Penn Township home, smiling and joking with the aide who is checking his blood pressure.

At 103, Rockman's mind is sharp he follows the morning stock market reports with keen interest but his body is worn. Last year, after a hospital stay, he was diagnosed with congestive heart failure, a condition common in the elderly, and for which there is no cure.

His son Dan and daughter-in-law Mary care for Rockman with the help of nurses and aides from Blue Mountain Health System's Home Health Care program, based in Lehighton. The care is crucial in keeping Rockman as healthy as possible to avoid another hosital stay.

Under a new policy implemented last October by Centers for Medicare and Medicaid, if heart failure patients like Herman Rockman are readmitted to a hospital within 30 days of their discharge, Medicare penalizes the hospital by docking payments.

The policy is called the Hospital Readmissions Reduction Program. The program, part of the federal Affordable Care Act, is pushing hospitals to double down on keeping those patients from being readmitted.

According to a report released in April by the Pennsylvania Health Care Cost Containment Council (PHC4), about two of every 15 adult hospital stays, or 13.5 percent, in the state in 2010 were followed by at least one readmission within 30 days of discharge.

"Readmissions in Pennsylvania cost the federal Medicare program close to a half-billion dollars in the most recent year for which data was available. In 2009, Medicare fee-for-service paid a total of $498 million for repeat stays that occurred within 30 days alone (not including the original hospital stay) in the state, covering 36.8 percent of all readmissions. In Pennsylvania, Medicaid fee-for-service paid for 3 percent of all readmissions that occurred within 30 days, a total of $29 million in payments," PHC4 spokesman Gary Tuma wrote in an April, 2012 press release.

Congestive heart failure is Medicare's "number one diagnosis," says Inge Allen, director of Blue Mountain Health System's Home Health Care program. "It's the one that costs them the most money. That is the number one reason why Medicare patients are rehospitalized. As of Oct. 1, 2012, if a patient is admitted with congestive heart failure, and they are discharged today and go home, and are readmitted to the hospital for any reason within 30 days, the hospital will get a penalty on that readmission. Either all or part of the admission will not be paid for."

The penalty hits regardless of which hospital the patient goes to within that 30-day period, or for what reason.

"So someone with heart failure today could fall and fracture their femur tomorrow and end up back in the hospital, and the hospital will pay a penalty for readmission," Allen says.

CMS figures that 2,217, or about two-thirds, of hospitals across the nation will be penalized by up to 1 percent of their Medicare reimbursements. Those penalties will increase to 3 percent by 2015. CMS expects to recoup $280 million from those hospitals penalized in 2013 alone.

Gnaden Huetten had a readmission penalty of 0.17 percent as of March. Palmerton's penalty was 0.36 percent, according to a Kaiser Health News analysis of CMS data. The corresponding dollar amounts were not available.

CMS expects to recoup $280 million from the 2,217 hospitals penalized in 2013 alone, according to a March 28 article in the New England Journal of Medicine.

The authors, Karen E. Joynt, M.D., M.P.H., and Ashish K. Jha, M.D., M.P.H, wrote that the CMS readmissions reduction program could, over time, help hospitals become better. But changes are needed.

"The latest data also make it clear that the HRRP will penalize hospitals that care for the sickest and the poorest Americans, largely because readmissions are driven by the severity of underlying illness and social instability at home. Simple changes to the program could ensure that incentives were provided to hospitals to improve coordination of care without hurting the institutions that care for the most vulnerable patients," they wrote.

Avoiding

readmissions

CMS is considering expanding the penalties by 2015 to include patients who have had total knee or hip replacements, or who have chronic obstructive pulmonary disease.

Hospitals have been working to keep readmission rates down.

The readmission rates for all patients, not just those on Medicare, are dropping, says Cindy Hipszer, project manager, PA Hospital Engagement Network for the Hospital and Healthsystem Association of Pennsylvania. She attributes the decline to the "increased engagement of hospitals in reducing readmissions."

Hospitals have several means to help them reduce the rates.

"There are many different intervention tools available. In our project, we have some hospitals using BOOST, a readmissions prevention program through the Society of Hospital Medicine; and others using Project RED (Re-Engineered Discharge), including Gnaden Huetten and Palmerton hospitals," Hipszer says.

Project RED has 12 components: Making appointments for follow-up medical appointments and post discharge tests/labs; planning for the follow-up of results from lab tests or studies that are pending at discharge; organizing post-discharge outpatient services and medical equipment, identifying the correct medicines and a plan for the patient to obtain and take them, reconciling the discharge plan with national guidelines, teaching a written discharge plan the patient can understand, educating the patient about his or her diagnosis, assessing the degree of the patient's understanding of the discharge plan, reviewing with the patient what to do if a problem arises,expediting transmission of the discharge summary to clinicians accepting care of the patient, and providing telephone reinforcement of the discharge plan.

The programs appear to be working.

In February, Deputy Administrator and Director for the Center of Medicare Jonathan Blum testified before a U.S. Senate committee that the national readmission rate dropped to 17.8 percent in the last quarter of 2012. The rate had hovered between 18.5 percent and 19.5 percent over the previous five years.

Reducing the rates is a team effort.

"People need to understand that this is a transition of care it will need to involve not just hospitals, but skilled facilities, post-acute care, community services, and patients all working together," Hipszer says.

A crucial

component

Close monitoring of congestive heart failure patients after discharge is key in avoiding readmission. One of the most efficient ways to do that is through programs that send nurses and aides to the patients' homes.

"Patients do so much better at home. For every extra day a patient is in the hospital, the more likely they are to develop complications that are either unrelated to why they are in the hospital, or that they didn't have when they came to the hospital," Allen says.

So now, instead of getting general advice upon discharge, heart failure patients are given specific instructions.

"Make sure you weigh yourself every day. If you see rapid weight gain, call your physician, because that could mean that you're going back into heart failure. Quit smoking, follow a healthy diet, watch your salt intake. These are things to start the ball rolling with the teaching before the patient even goes home," Allen says. "We try to help the patient understand that they have a responsibility for their health care as well. They need to take care of themselves so that they can stay out of the hospital."

The lifestyle changes can offer a patient a better quality of life, if not a longer one. Congestive heart failure typically carries about a five-year survival rate.

"You have to make a choice. Do you want to spend those five years at home with your family? Or do you want to spend them going in and out of the hospital?" Allen says.

She points out that congestive heart failure patients' hospital stays are not as long as they used to be. Now, they are usually a couple of days, as opposed to about five days just a few years ago.

"So it's critical to get into those patients' homes, and monitor them closely,' she says.

That's what BMHS Home Health Care does for Herman Rockman.

"With him being 103 years old, they are the ones who keep him out of the hospital," says Dan Rockman. "They teach us how to take care of him, and we have somebody to call on a 24-hour basis. Without them, I don't think we'd be able to keep him out of the hospital."

The Rockmans rely on the Home Health Care program.

"There's no doubt in my mind that we wouldn't have Dad if it weren't for these wonderful ladies," Mary Rockman says. "He'd be in a nursing home or a hospital if it wasn't for them. We're not trained professionals, but we've learned a lot, and they are a phone call away."

The Rockmans speak fondly of the Home Health Care nurse, Jennifer Blasko, and aide, Sonya Fisher, who bathe, monitor and provide medical care for Herman. Blasko and Fisher laugh with Herman, and he is excited about Sonya's expected baby, occasionally patting her belly.

"It's more than somebody coming into the house, helping us and helping my Dad. They've become family," Dan Rockman says.

The Rockman's appreciation extends to Supervisor Maria Kotze, crediting her with setting a positive tone.

"I don't know what we'd do without them," Mary Rockman says. "This is our safety net this is who we trust."