Julie Hontz juggles her smartphone at a red light, quickly punching the address of a nursing home she's never been to into the GPS. The home marks her first patient visit of the day: a 91-year-old woman in short-term rehab.

The two met the week prior, when the patient first wound up in the hospital for congestive heart failure. Hontz recalls the patient was sick, sleepy and "had this new diagnosis she was a little overwhelmed with."

Even so, the two hit it off.

Hontz, a masters-trained nurse, has a clear mission today: help the patient transition home and prevent her from returning to the hospital for an unplanned readmission. But achieving that outcome for this patient and others is rife with challenges. It's one that's plagued the health system, communities and families for decades.

As awareness of this problem grows and Medicare penalties kick in for places with high readmissions rates, that has hospitals, payers and providers starting to look to new models of care that extend outside the health system's doors—and to roles like that of Hontz's—to better understand and handle the problem.

Navigating through swiss cheese

Hontz's visit with the patient at the nursing facility lasts about 45 minutes. During that time she learns the patient has been on a regular diet, not a low sodium one—the patient didn't realize the frozen dinners she likes to eat at home are high in sodium. Even a few days with that meal plan, Hontz says, could trigger a sudden return to the hospital.

"She could end up with fluid in her lungs and congestive heart failure," she says.

She alerts the staff. Hontz then discovers the patient's upcoming doctor's appointment isn't on the facility's schedule, so she could potentially miss it.

"There's so many potential for holes," says Hontz, who likens her work to navigating through swiss cheese and constantly trying to fill those holes.

A fragmented system

"The problem you're looking at is that care is immensely complex, and it's fragmented," says Steve Jencks, a health care consultant and former Medicare official who has spent decades examining quality of care and safety issues. "Not only does the left hand not know what the right had is doing, but the index finger doesn't know what the thumb is doing."

Jenks led an influential study on hospital readmissions in 2009 that found one fifth of seniors admitted to the hospital returned within a month from being discharged. That led to more complications down the road, and the estimated cost for unplanned visits hit nearly $20 billion in 2004.

"That seems like a lot of people, and a lot of readmissions, and a lot money and a lot of misery," Jenks says.

Since the study, Medicare has started penalizing hospitals with higher than expected readmissions rates, including many in the Philadelphia region. That has places beginning to look at how to create better transitions into the community. It might be as simple as making sure patients have their medication in hand before leaving the hospital.

Jenks says the approaches are promising, though small in scale. He hopes that ultimately, they all connect instead of adding new layers of complexity—and new holes—to an already complex system.

The transitional care model

Hontz is one of three transitional care nurses who works out of Penn Care at Home in Bala Cynwd. She was drawn to the program after working for over a decade inside a hospital, where she kept seeing patients return but didn't understand why.

"And you just wonder what was going at home, that they weren't able to manage their disease appropriately," says Hontz. "[in the hospital] You treated their acute exacerbation, and then said goodbye, and you had no idea what happened afterwards."

Hontz and the two other nurses have a big task at hand, with the three of them responsible for helping seniors with diseases like diabetes, heart failure and chronic bronchitis who wind up at any of Penn's three hospitals transition back into the community. From there, the goal is to help patients learn how to manage their disease on their own.

The idea is to meet patients when they're first hospitalized, establish a relationship and understanding of their discharge plan, and then follow up with them at home within 24 hours of discharge. The nurses then regularly follow up—often in person—for anywhere from three to nine months, depending on the patient's insurer. They only serve seniors enrolled in one of two Medicare Advantage plans, because that's who reimburses them for care.

The transitional care model is the brainchild of Mary Naylor, a professor of nursing at Penn's School of Nursing. She started the program five years ago, and believe it or not, she says it represents a huge shift in health care culture.

"Systems don't change overnight," she says.

Naylor, who is part of a federal Medicare payment commission, worries about the limited health care resources for an aging society with increasingly complex health needs.

She has spent decades trying to figure out why some patients wind up back in the hospital unnecessarily and what sorts of steps nurses like Hontz can take to change that, whether that be better educating patients about their medication and diet, going over what to do if their symptoms get worse, or making sure they're able to connect with follow-up care.

Naylor's optimistic. More institutions are adopting the transitional care approach in some way, and overall, readmission rates are starting to go down.

"We do know that people with chronic illnesses, we can help them prevent these acute episodes of chronic illness that land them unnecessarily in [the] hospital," she says. "That's central. That's core to have people be able to enjoy the quality of life they deserve."

Home: the final stop

After taking a midday cafeteria break, Hontz visits with recently admitted patients to Pennsylvania Hospital. She and the other nurses receive a list each day of patients who've been hospitalized all across the health system.

Hontz's final visit of the day is to Ruth Gordon's home. Gordon is one of fifteen patients Hontz is actively following in the community. Gordon is 87 and petite, and she cares for a son who has intellectual disability. She's doing her best to manage her own congestive heart failure and other health problems.

Hontz checks Gordon's vitals and asks how she's feeling.

"Any chest pain or shortness of breath?"

"No," Gordon responds.

Hontz knows it's essential Gordon take her medicine every day. Otherwise she could wind up back in the hospital.

Gordon has over a dozen prescriptions. It's confusing. During an initial visit, Gordon admitted that she sometimes missed doses. Hontz, working with Gordon's doctor, then simplified the regimen to make it easier for her to keep track her pills and stay on schedule. Gordon says it's really helpful.

"She explains everything to me, a lot of things I didn't even know," says Gordon. "Your primary doctor or hospital, they don't tell you everything. But I want to know."

Hontz patiently reviews the medications with Gordon, making sure she knows what each is for. She gets to a really important bottle. It's empty.

"Do you remember having it in the box for today?" she asks.

"Yeah," Gordon responds.

"So it just ran out," says Hontz, counting just a few days left in Gordon's pill box.

Gordon tells Hontz she called the pharmacy, but they didn't have the prescription. Hontz calls, and tries to figure out what's going on.

Their visit is a lot longer than usual. By the time Hontz leaves, it's getting dark.

"It is overwhelming at times," she says. "You really work to cover and close those holes as best you can, but some holes you can't, and you have to be okay with letting those go."

It's after five. Hontz says it was a pretty good day, as she thinks she was able to prevent some problems. Now, she says, it's time for her to go home.

This story was updated on Monday, February 23.