A new program aims to help thousands of Medicare patients in Whatcom County after they leave the hospital, with the goal of reducing preventable return visits.

Set to begin in mid- to late-September, the program will use coaches to help manage information over four weeks for qualifying seniors in what is known as "original Medicare."

"These coaches will be that bridge to help the patients when they go home, and the patients' families, (to) understand what they need to know so they don't need to be back in the hospital," said Elya Moore, development coordinator for Whatcom Alliance for Healthcare Access.

The federal Centers for Medicare and Medicaid Services selected the county to participate in the initiative, which is called Whatcom Impact Project: Improving Care Transitions.

The program would help about 1,700 Medicare patients in Whatcom County a year for at least two years.

Seniors need help with information because leaving hospital care can be stressful, organizers said, and it's a time when patients may be sad or exhausted.

So they might not understand, for example, the type of medication they need or how much of it to take, or the importance of booking a follow-up appointment with their doctors within a week of being released from the hospital.

"We know and have known for many many years that when folks go to the hospital and then they're discharged, there are a lot of things that can go wrong in a transition," said Victoria Doerper, executive director of Northwest Regional Council.

The council, which also serves as the Area Agency on Aging, is one of the partners in the new program.

The other primary partners are Whatcom Alliance for Healthcare Access and PeaceHealth St. Joseph Medical Center, although other medical providers in the county are participating.

In Whatcom County, the goal is to reduce Medicare beneficiaries' hospital readmission rate within 30 days from 14.3 percent in 2012 to 10.7 percent in 2014.

Doing so would reduce stress and suffering for patients, program backers said, as well as cut the cost of health care.

"The whole model is to basically empower people to better work with their own health care team and to be confident in that," Doerper said. "It's also to reinforce the information that they received upon discharge."

LEARN MORE

For information about Whatcom Impact Project: Improving Care Transitions, email Elya Moore at eemoore@hinet.org.

Reach KIE RELYEA at kie.relyea@bellinghamherald.com or call 715-2234.