Ruth Ratajczak knew that the elderly man was in trouble.

Only a few days before, he had been hospitalized with internal bleeding. Now back home, he told her he was taking Coumadin, a blood thinner. In his condition, she knew, that could be disastrous.

"I said, 'You know what, let's call your doctor.'" The doctor promptly took him off the drug. And spared him a return trip to the hospital.

For Ratajczak, that was a success story -- even if it meant less money for her employer. As a so-called transition coach at St. John's Hospital in Maplewood, it's her job to keep patients from coming back too soon.

Until now, hospitals have had little incentive to keep patients away. But last week, the federal Medicare program started imposing financial penalties on hospitals that, in its view, have too many repeat customers.

The change, part of the 2010 federal health reform law, was prompted by research showing that 20 percent of Medicare patients who leave the hospital are readmitted within 30 days -- often because of medication errors or other missteps.

And that has shifted attention onto what hospitals can do differently to help patients after they go home.

"What used to happen is we would call patients when they left the hospital," said Karen Tomes, director of Care Management at Allina hospitals. Basically, it was little more than a courtesy call to make sure they understood their medications. "The patient would say yes, and we'd move on."

What they discovered, however, was that many patients are ill-prepared for going home from the hospital, especially after a heart attack or surgery, and end up bouncing back with complications.

One study found that almost half the time, patients have medication mixups when they get home.

"There's so much that happens when you're here in the hospital," said Ratajczak, 59. "Then you go home and it kind of hits you: 'Wait a minute, what am I supposed to do now?'"

For more than a year, Allina and other hospitals throughout Minnesota have been experimenting with ways to smooth those transitions as part of a statewide collaborative called RARE (Reducing Avoidable Readmissions Effectively). And they're making progress: Since January 2011, Minnesota hospitals collectively have reduced readmissions by about 2,600, according to the Minnesota Hospital Association.

No charge, no obligation

One of those experiments began at St. John's Hospital five years ago, when Ratajczak became its first transition coach. Since then, HealthEast, the hospital's parent company, says it has cut the readmission rate for patients in the program to 9.7 percent.

"We know that we're making a difference," said Pennie Viggiano, the project supervisor.

Most mornings, Ratajczak makes her rounds at St. John's searching for "high risk" patients who might need her help. Typically, she looks for patients with certain conditions -- heart failure, diabetes, lung or heart disease. Age is a factor, too.

Most people, she knows, have never heard of a transition coach. So sitting at a patient's bedside, she explains that her job is to "make sure that when you leave the hospital and go home, it goes as smoothly as possible."

There's no charge and no obligation, she says. But if patients are willing, she'll call when they get home and pay a visit within a few days.

The idea of a transition coach was created by Dr. Eric Coleman, a University of Colorado physician who just last week won a MacArthur genius grant for his innovations.

The problem, he said, is that patients are often confused and overwhelmed when they leave the hospital.

"A lot of them are sleep-deprived and are given drugs that affect their brain," Coleman said. At home, things can quickly spin out of control, especially if they can't afford a drug or can't get a ride to the doctor. "That's the sort of stuff that's tipping them over the edge," he said.

A coach, Coleman said, concentrates on teaching patients the skills they need to fend for themselves: whom to call, when to call, what to do if they need help.

Discrepancy uncovered

One afternoon last week, Ratajczak perched on a living room couch in White Bear Lake and studied her hostess, 97-year-old Beatrice Kellgren.

Kellgren didn't look like she had just come home from the hospital; she was dressed comfortably in a soft fleece jacket and white turtleneck. She had gone to the emergency room with chest pain, she said, but the doctors hadn't found anything wrong. Now she was just glad to be back home.

Although Ratajczak is a nurse, she wasn't there to take blood pressure or give injections, just to talk.

After running through a checklist of topics (the risk of infection, the value of living wills), she asked Kellgren to show her what medications she takes.

Kellgren led her into the kitchen and handed her a handwritten list of medications. "This is exactly what I take," she said.

Ratajczak compared the handwritten note to a hospital printout -- and found a drug that didn't match. "The doctors at the hospital did not order that for you," she said gently.

Kellgren couldn't explain the discrepancy. Then she pulled out another bottle of pills, which she hadn't touched. "They told me to take it every day," she said, "then I saw what the side effects were."

Ratajczak's advice: See your doctor as soon as possible to straighten this out.

"I will," Kellgren assured her.

A 'revolution' in health care

So far, transition coaches have spread to a number of hospitals in Minnesota, but not all. One of the problems is cost, admits Kathy Cummings of the Institute for Clinical Systems Improvement, which is running the state's hospital readmissions collaborative. "Some organizations [have] said, 'We just can't swing that right now.'"

HealthEast says one of its insurers is helping to cover the costs of its three coaches.

For now, however, many hospitals are caught in the middle. They lose money if they reduce readmissions and they face Medicare penalties if they don't.

At the same time, Cummings said, there's widespread agreement that hospitals have to do more to slow the revolving door of admissions.

"We are in a revolution in health care, and we really have to do some things differently," she said. "It's the right thing to do."

Maura Lerner • 612-673-7384