Congestive heart failure is a particularly big target, as one in four patients end up back in the hospital within 30 days of discharge. Starting in the fall of 2012, the government will cut Medicare reimbursements for hospitals with higher-than-expected 30-day readmission rates for heart failure, heart attack and pneumonia, making it the hospital's responsibility to prevent patients from needing to return.
At Thomas Jefferson University Hospital, it took more than a week to get Pierre Trombert's congestive heart failure under control and send him home. To insure that he would not get rehospitalized, Joanna Heil, an advanced-practice pharmacist at Jefferson, gave Trombert a scale and called his home to ask if he was weighing himself. She reminded him about doctor's appointments and followed up to see if he went.
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