David Norlund went home with nine separate medications when he left the hospital after treatment for pulmonary disease last month.

With so much to keep track of, it’s no wonder that roughly one in five older patients winds up back in the hospital within a month of being discharged — a number that is costly for the health care system and hard on the patients.

But the next day, a nurse came to Norlund’s house in Fridley to explain when and how to take his meds — even organizing them in a pillbox.

The house visit was part of a pioneering effort by a coalition of Minnesota health groups to prepare patients to recover at home and avoid a return trip to the hospital. The campaign, which prevented an estimated 6,211 readmissions between January 2011 and 2013, just won a major patient safety award from the National Quality Forum and the Joint Commission on Hospital Accreditation.

‘Meet the needs of the patients’

The key was simple changes in the way doctors and nurses talk to patients, according to Lawrence Massa, president and CEO of the Minnesota Hospital Association, one of the partners in the project. “In the old days, we just assumed patients understood what we told them and we checked it off the list,” he said. “… Now we’re trying to modify our whole communication to meet the needs of the patients.”

Reducing readmissions is not just good for the patient, it’s good for the hospital as well. The Affordable Care Act of 2010 included financial penalties for hospitals that have excessive Medicare readmissions for heart attack, heart failure or pneumonia. Two-thirds of the nation’s hospitals, including many in Minnesota, were fined under that provision last year. While that rule focuses on those three health conditions, the Minnesota campaign — called Reducing Avoidable Readmissions Effectively — has worked to decrease readmissions for all patients.

‘Gulf between the silos’

One key is promoting communication among all the professionals caring for a patient — so the pharmacist and nursing aide, for example, know exactly why the surgeon prescribed a certain drug. “Health care has been kind of siloed, and where the patient gets into trouble is in the gulf between the silos,” said Kathy Cummings, project manager at the Institute for Clinical Systems Improvement in Bloomington, another of the partners.

Other simple strategies include making follow-up appointments before the patient leaves the hospital and asking the patient to repeat back any instructions the doctor gives them.

Allina Health, which has 11 hospitals in the campaign, revamped its discharge instructions to reduce medical jargon and ensure that patients could get clear information once they got home, said Karen Tomes, an Allina vice president.

But campaign partners will have to keep working together to see continued results. Cummings said, “We have needed a partnership between all of the key players.”

Rebecca Harrington is a University of Minnesota student reporter on assignment for the Star Tribune.