By John Reichard, CQ HealthBeat Editor

When patients leave the hospital they often don’t get the detailed instructions or reminders they need to ensure proper follow-up care, contributing to costly readmissions to the hospital, researchers say. Now some lawmakers, with the backing of the senior lobby AARP, are trying to ensure a smoother transition with legislation that would require Medicare pay claims for “transition” services, such as issuing detailed instructions for patients and caregivers to follow at home.

Health overhaul bills under development by the Senate Finance and Senate Health, Education, Labor and Pensions committees include “pieces” of such legislation but AARP would like to see the measures include specific language being introduced this week by Sens. Jeanne Shaheen , D-N.H. and Susan Collins , R-Maine, AARP Legislative Policy Director David Certner said in an interview.

“It’s unacceptable that 20 percent of people in Medicare who visit the hospital will return within a month, often because they aren’t getting the follow-up care they need,” said AARP Executive Vice President Nancy LeaMond in a statement. “We’re sending home too many people with a handful of prescriptions and no support. Something as simple as help to set up a medication schedule could be the difference between getting healthy or winding up back in a hospital bed.”

Democrats on the two Senate committees are laboring to lower the costs of their proposals, whose estimated costs are fueling skepticism that Democrats can accomplish a major overhaul of the health care system. But Shaheen’s press secretary, Alex Reese, said the legislation would save Medicare money overall despite the up-front outlays for claims because of savings from a reduction in hospital readmissions. Certner agrees, seeing the fact that Democrats are seeking ways to reduce the costs of their proposals as working in favor of the legislation. “If anything we think that probably strengthens the case,” Certner said.

But the Congressional Budget Office hasn’t scored the cost of the Shaheen-Collins legislation, which is slated to be introduced Thursday.

According to Shaheen’s office, the benefit would pay a “transitional care clinician” — generally a registered nurse with special training — for such services as: developing a transitional care plan that identifies potential health risks, treatment goals, current therapies, and future services; reviewing medications to avoid adverse drug reactions, and teaching the patient and caregiver how to organize, manage and take medications; monitoring follow-up physician visits by the patient; assuring appropriate referrals to specialists, tests and other services and help with navigation of the health care system; and assisting the patient and caregiver with coordinating support services such as medical equipment, meals, shopping, and transportation.

Boosters point to the research of University of Pennsylvania researcher Mary Naylor to make the case that the benefit would more than pay for itself. Applying transitional care services to Medicare patients with two or more risk factors saved almost $5,000 per patient over the course of a year, according to research cited by Naylor at an April 17 Senate Finance Committee “roundtable.” The risk factors included a history of recent hospitalizations, multiple chronic conditions and poor self-health ratings.