At the University of Utah, nurse Stephanie Wallace links high-risk patients to the outside care that could keep them from returning. And she’s the one whose phone rings when that care falls through.

Consider the single mother who couldn’t afford post-hospital blood tests to make sure her blood-thinning medication was working properly, or time off work to get them and didn’t speak enough English to seek help. When the woman missed her lab appointment, Wallace pieced together the trouble, helped her enroll in a program for low-income patients — and stressed the importance of sticking with this care.

“It’s not that they don’t understand why they’re sick. They don’t grasp the importance of why they need follow-up,” Wallace said.



The customized programs reflect the Dartmouth study’s findings that there’s great geographic variability in hospital readmissions.

In Miami, for example, more than a quarter of Medicare patients with heart failure returned to the hospital within a month in 2010, the latest data available. That’s double the readmission rate for those patients in Provo, Utah.

In Dearborn, Mich., the readmission rate for pneumonia was 20 percent, twice that of hospitals in Salt Lake City.

“Every place is different and faces different challenges in terms of improving care after patients are discharged from the hospital,” Goodman said.





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