Clifford Lynd Sr. is breathing easier these days. In the heat of the summer, he's feeling strong enough to paint a booster chair he built for his great-granddaughter. "I can always find something to do," said Lynd, a 79-year-old retired meat cutter who lives in Philadelphia. "I have lawn chairs that need new webbing, and I'm refinishing an end table for my grandson."

Lynd would have had trouble tackling these projects a year ago. In July 1998, he was hospitalized with congestive heart failure. He was readmitted in September. "The last time I went in, I had been to church on Sunday morning. I stopped by to see my youngest daughter, who is our family doctor's office manager. When she saw that I could hardly breathe--my lungs were filled up with so much fluid I was panting--she took me right to the hospital."

Congestive heart failure is a chronic debilitating disease. Typically, patients like Lynd are in and out of the hospital. They suffer fatigue, shortness of breath, fluid buildup in their lungs, sleeplessness. The heart muscle is weakened, unable to do its job pumping blood to the lungs and through the rest of the body.

Without proper care, Lynd's condition would have deteriorated. But he was able to take advantage of a research project at the University of Pennsylvania School of Nursing that provides continuing care for seniors. In this ongoing study, patients are paired up with specially trained nurse practitioners who monitor their care during and after hospitalization. The goal is to see if careful management of the transition from hospital to home can help patients recover better and prevent readmissions.

The study, conducted by Mary Naylor, an associate professor at the nursing school, has so far followed 363 elderly patients with encouraging results. According to a report in the Journal of the American Medical Association, many patients can regain control over their lives, avoid hospital readmissions and save taxpayers thousands of dollars in Medicare costs when they receive comprehensive transitional care from highly trained nurses.

Within 24 hours of his last hospitalization, Lynd was put together with Brian Bixby, a nurse practitioner with advanced training. Bixby monitored Lynd's care through his hospital stay and followed up by visiting him at home, sometimes twice a week, for the next four months.

"Brian used to come sit right next to my easy chair," recalled Lynd. "He'd sit on the sofa and we'd talk like we were buddies for years and years. We talked about what the medicines I was taking were for. He kept track of my weight. He went right into the pantry in the kitchen and picked out different things and said, 'Don't eat this and don't eat that. Canned goods have too much salt in them.' I didn't know. I was a meat cutter. I didn't know a slice of bacon had so much salt."

Sicker and Quicker

Bixby helped Lynd change his diet and taught him about his medications to ensure that he was taking them properly. In years of research, Naylor said, she has found that with chronic diseases like congestive heart failure, "the whole idea is to position individuals in terms of their diet, exercise, sleep and medications so they don't run into trouble."

Naylor is concerned that "more and more elders are being discharged from the hospital with unresolved health problems, forcing the home care end to pick up more and more acutely ill people."

At the same time, cuts in Medicare coverage, especially in the past few years, have resulted in "shorter hospital stays and decreased access by this population for home care. What happens to individuals as a result . . . is that they don't get better," said Naylor.

Hospitalization can be very stressful for patients. In two or three days, nurses generally are unable to teach patients enough about their condition to prepare them and their families for life at home. Patients are confused, tired and scared.

"Many of these individuals are so stressed by their problems that hospitalization is not the best time to be teaching them about their medications, what to expect after recovery or the changes they need to make in their daily routine," she said.

Nurses also have little time to assess what conditions will be like at home. Will there be someone there to help the patient bathe, shop, buy food and medications? Can the patient follow the post-discharge instructions that the physician has prescribed?

Naylor's complaint with rushing patients through the hospital is that there hasn't been any "planned, systematic effort" to insert supports that will ensure "positive health outcomes." She is convinced that shortening inpatient care by two or three days has led to many unnecessary readmissions to the hospital. Naylor estimates that "at least a third of these readmissions are preventable.

"You know there are tremendous costs for individuals to be in and out of hospitals. Unfortunately, we have a system that has perverse economic incentives. We're not talking about how to invest resources to best achieve long-term positive outcomes for elders and their families. We're [only] talking about cutting costs in hospital care."

Naylor's study followed 363 senior citizens hospitalized for heart disease, orthopedic and small and large bowel procedures, and respiratory tract infections. She found that patients who received intensive at-home follow-up did significantly better. Compared to a control group that received standard discharge care, the patients receiving intervention by trained professionals had fewer readmissions to the hospital, saving Medicare an average of $3,000 per patient during the six months after their original admission.

The study depended on "advanced practice" nurses with training in geriatrics to assess the patients' physical, emotional and social condition in the hospital and determine what support services would be needed at home.

Collaborating with physicians, family members and other health professionals, the nurses designed individual discharge plans for every patient. They taught patients and the people who would be involved in their care at home about prescribed medications and dietary requirements. They recommended levels of exercise and activity and made follow-up medical appointments. They pointed out potential symptoms and early warning signs of complications that might occur.

Home visits were an integral part of the program. The program's nurses were also available by telephone. All in all, they acted as the go-between for patients and the rest of the medical community. They talked to the patients' doctors when questions or problems arose. They helped patients enroll in supplemental insurance plans and arranged for additional in-home care services. They also found support services for the patients' spouses.

The comprehensive effort paid off. According to the report in JAMA, 20 percent of the intervention group had been rehospitalized within 24 weeks after discharge, compared with 37 percent of the control group. The Medicare costs for rehospitalizations were approximately $600,000 less for patients who were part of the program.

Home as Hospital

Today's Medicare system is so fragmented that patients can fall through the cracks between hospitals and outpatient services.

"Hospitals are paid out of one pot of money. Home health care is paid out of another, and doctors are out of a third pot. The rules for each of these pots are different, and the financial incentives are not necessarily going in the same direction," explained Peter Boling, a physician and associate professor of medicine at Virginia Commonwealth University Medical College of Virginia.

The common economic denominator in all sectors of health care is to get patients in and out as quickly as possible. The shorter the hospital stay, the less time in a doctor's office, the fewer home care visits, the better for the bottom line. "All these care environments are under increasing pressure to reduce the duration and intensity of services," said Boling. To be sure, many patients in the past were subjected to unnecessary treatments. In the current trend of managed care, the financial incentives are geared to reducing such services. But for many people, the result is that they are squeezed out of care that they believe they need, and bounced around from one part of the health care system to another.

"Patients would be better served if hospitals were viewed more as a continuum, rather than as a completely separate episode," said Kenneth Covinsky, a physician and assistant professor of medicine at the University of California San Francisco. The Naylor study is important, he said, because nurses get involved in the care of patients during hospitalization and are active in the transition from the hospital to the outpatient setting.

"When we were residents we were always taught that good discharge planning began on the day of admission. We were taught to think about the patients' living situation before they got into the hospital and what it was going to be like after they got home," said Covinsky, who graduated from medical school in 1988.

Since he began practicing medicine, Covinsky has seen that the "lengths of stay [for hospitalized patients] are going down, so it's clear that a lot of what we used to do in terms of stabilizing patients in the hospital now has to be done at home. The role of an intervention like Naylor's can fill that gap. And having close follow-up at home can help patients from falling through the gaps, because it is hard to predict those patients who are going to do well when they go home and those patients who are not."

Hospital stays began to decrease in the early 1980s when Medicare introduced its prospective payment system and paid a fixed price based on diagnosis.

"Until the '80s, patients remained in the hospital until the acute problem was resolved, blood work or other diagnostic tests were completed, or a social situation that prohibited discharge to home was resolved," said Robert Palmer, a geriatrician at the Cleveland Clinic Foundation in Ohio. "A patient could be in the hospital for 10-14 days and have a complete work-up. Once the reimbursement was fixed, hospitals had an incentive to get patients out as soon as possible."

Today, this incentive is the driving economic force behind hospital care. If Medicare covers five days in the hospital for a particular diagnosis and the hospital keeps a patient for 10 days, the hospital still only gets paid for five days. If, however, a patient with the same diagnosis is released in three days, the hospital gets paid for the whole five days.

Christine Cassel, chairman and professor of geriatric medicine at the Mount Sinai School of Medicine in New York City, said that Naylor's study illustrates the importance of transitional care from hospital to home.

"It is intuitively right to me as a geriatrician," she said. "Older people have so many complex issues. They have multiple diseases. They are on multiple medications. It can be hard for them to understand what they are supposed to do. Because they are going home sooner, the family or situation at home becomes almost an extension of the hospital."

Unfortunately, patients and families are not always attuned to the "red flags" that would alert an advanced nurse practitioner or physician to the onset of a crisis. Congestive heart failure or pneumonia in the early stages can often be treated at home, but caregivers have to know when prompt medical care is needed. A nurse who has followed a patient through the hospital is better able to spot subtle changes requiring attention and reassure the family that proper steps are being taken.

"Nobody pays for this kind of care right now," Cassel said.

Clifford Lynd is grateful for just that kind of care. Since his last hospitalization in September, he has not fallen victim to the downward spiral of congestive heart failure. He credits Naylor's project and Bixby's work with changing his life and giving him a cushion of support when he was sick.

"After I was in the hospital, Brian was somebody I could always count on," said Lynd. "If I needed anything I could call him. If I didn't get him right away, he would call me back. I still have his phone number and I can call him at any time, though I haven't had to.

"He explained everything to me and my wife. He told me what to eat and when to take my medicine. If it hadn't been for Brian," Lynd said, "I would still be eating all the salty food I always ate and I would have been back in the hospital."

CAPTION: Clifford Lynd Sr. says the home care he received after hospital treatment for congestive heart failure enabled him to resume tackling projects in his garage workshop.