If you've ever been to the hospital, you know it can be tough to get home and then follow all the various new drug regimens or wound care instructions.

And for people who have complex medical issues, or problems such as depression, those instructions can be overwhelming. So much so in fact, that patients regularly end up right back in hospital.

Oregon Health and Science University has developed a new program to tackle this problem -- with the goal of not only keeping patients healthier, but also saving money.

Readmissions are something that 54-year-old, retired TriMet driver, Julie English knows all about.

Kathryn Boyd-Batstone / OPB

Julie English has been readmitted to the hospital three times and now receives help from Leah Croft, a Transitional Care Nurse.

She's diabetic. She has high blood pressure and suffers from cellulitis -- a skin infection that causes an itchy rash. It's so painful in fact, that in April, she ended up in hospital for a couple of days.

Sitting comfortably at home now, with her cats and fish tanks, she explains how she was released.

"So the pain had gone away and the redness had pretty much gone away. And there was really no blistering and I felt a lot better, the fever was gone. And so the doctor decided that you know, I was probably going to be okay. So they prescribed some antibiotic to go home with and that was kind of it."

What about instructions for home care?

"They didn't really say a lot in the report that I took home, as far as what I should do and stuff, I mean if the fever starts in again or that kind of thing. I don't think they mentioned anything about the blistering or anything. So, I kind of didn't really know what to do."

She says she took the antibiotics she'd been prescribed. But then, her rash got really itchy and she started to scratch.

"Blistering started in probably three days after I got home."

So, she went back to the hospital and was there for four days. Her stay was covered by her insurance. But readmissions cost insurance companies and the government a lot of money.

As part of federal health care reform, the Centers for Medicare and Medicaid Services started reducing payments last year to hospitals that didn't tackle the problem.

So this time, before she was released from the hospital, English was put in touch with OHSU nurse, Lea Croft.

"I met Julie, pretty close, it was the day that she was actually leaving the hospital and I had been able to identify her as someone that was most likely going to need some additional help when she got home. She had some pretty complicated wound orders in place and a whole lot of other just kind of things that the potential for falling apart when she got home."

Kathryn Boyd-Batstone / OPB

Leah Croft (left) talks to Julie English (right) about the correct way to take her medicine.

English says having Croft's support made all the difference.

"Well, she's helped me a lot with the signs and symptoms and what to do. And she accompanied me to my doctor for the first visit after I got out of the hospital. I was prescribed some lotion that was extremely expensive, like $200 and she arranged through the insurance company to have them pay for it so I could get the medication and not have to pay for it. So she's been real helpful. And anytime I needed anything, she's been there for me."

Would English have bought the $200 cream herself?

"Probably not. It's not in my budget, so I would have just probably went without."

She says Croft arranged for home nursing care to come and change her bandages; take her blood pressure; and make sure she was eating lots of fresh fruit and vegetables. A physical therapist also came to install grab bars around the house. All of which she says, inspired her to take better care of herself.

"Just watch my sugars and be sure to take my pills in the morning and take my blood sugar my glucose in the morning too. Instead of willing-nilly like I had before. Be sure to stay on my pills, which sometimes I didn't always take. And start to try to get a little exercise too, maybe I could take off a couple of pounds and that would help."

KFV: "Have you done anything about that?"

JE: "Yeah I walk to the mailbox twice a days, which is about a block. And that was last week, then I can figure I can walk a block or two more every week."

Such lifestyle change is the hope of Dr. Honora Englander, who started OHSU's whole hospital-home program -- the Care Transition Innovation or C-TraIn.

Kristian Foden-Vencil / OPB

Dr. Honora Englander

Back in 2007 -- well before federal health care reforms -- Dr. Englander saw how often patients were being readmitted and she pushed administrators to look into the problem.

The C-TraIn program now has four main goals: First, using a transitional care nurse, like Lea Croft, to help patients tackle disease themselves.

Second, getting pharmacies to secure necessary drugs -- and to make sure patients take them correctly. Third, making sure a patient's primary care provider knows what the patient has been through while in the hospital. And fourth, to have hospitals and community clinics meet regularly to come up with new ideas.

Dr. Englander says that OHSU even pays three outpatient clinics for primary care of some uninsured patients.

"These direct clinic and hospital partnerships really build bridges. And so our inpatient teams previously worked independently from our outpatient teams. Now we have inpatient care managers and outpatient care managers that know one another and can work together."

But the question is, does the C-TraIn program save money?

"You know we can point to patient examples and say, 'Yeah we think we've improved utilization, prevented a readmission and also improved the quality of this patients' experience and improved their health.' I think the question of is what we're doing, especially in the context of the other health reform work that's happening, is that at a population level saving money? That's a question, we don't know that yet."

A grant, set up as part of the Affordable Care Act, is being used to figure that out. But meanwhile, the C-TraIn program is being scaled up in the Portland area, so it now covers OHSU and three Legacy Hospitals. Dr. Englander's hope is that the entire coordinated care organization -- Health Share of Oregon -- will take it on, along with other CCO'S around the state.

Meanwhile, it's been six weeks since Julie English left the hospital. She says the program helped her to handle her health better -- even reducing her salt intake.

"That kind of sunk in because I have a hard time getting shoes with one foot swollen and one not. So I really try to watch my salt now.

KFV: "You've know that before though, right?"

JE:"Yea, pretty much but I think time it kind of pounded in my head a little bit more."

KFV: "Is this a life change or is this just while they're looking over your shoulder?"

JE: "No. I think that I'll probably have to change it for a lifetime."

Many organizations have similar programs to reduce hospital readmissions.

The C-TraIn is more advanced than most, and also concentrates on Portland's economically vulnerable population.

But for Julie English, it means she can focus less on her health and more on some happy news for her daughter.

"She's pregnant with twins, identical twins, so I'm going to be a grandma for the first time and I'm really excited about that."

This story originally appeared on Oregon Public Broadcasting.

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