No one wants to end up in the hospital.

Worse yet, no one wants to end up getting readmitted to the hospital shortly after they've just been discharged.

For the patient, it's an unwelcome shot of life-misery. For the federal government, it's a financial blow amounting to $26 billion a year. Nearly one out of five Medicare patients who are discharged from a hospital - that's 2.6 million seniors - will be readmitted within a month. These figures have the federal government mightily worried and two sections of the Affordable Care Act (commonly known as Obamacare) deal specifically with the existence of this problem and ways to shrink it.

There is, however, encouraging news on the local front that might turn this high-risk trend on its head. The NIC Area Agency on Aging was recently selected as one of 35 pilot sites nationwide to participate in the community-based Care Transitions Program, a concept aimed at reducing hospital readmissions by following discharged Medicare patients with in-home visits made by specially-trained social workers.

Kootenai Health is one of three hospitals helping to develop and implement the local intervention program - Bridging Care Across the Inland Northwest. Also participating are Providence Sacred Heart Medical Center and Providence Holy Family Hospital.

"All sites are required to use an evidence-based intervention method," said Pearl Bouchard, director of the aging agency. "The term 'evidence-based' means that the intervention has been tested and revised until it has been proven to have the expected outcome."

Eighteen months in the making, the program emphasizes four post-discharge areas of care: medication self-management, dynamic patient-centered records, follow-up with primary care provider and recognition of red flags. To date, two social workers from the NIC Area Agency on Aging and one registered nurse at Kootenai Health have been trained as program coaches.

Bouchard said it is up to each hospital to decide which medical diagnoses present the greatest chance of readmittance within their Medicare populations. Kootenai Health has selected patients with congestive heart failure, arrhythmias, diabetes, chronic obstructive pulmonary disease, asthma, pneumonia, sepsis and previous 30-day admission.

Rose Mulcahy, a nurse at Kootenai Health, is the program's Care Transition Coordinator. While the participants are still in-patients, she introduces them to the post-discharge program. "Together, we identify the patient's goals and needs. We try to engage them in interventions and get them more involved, so they'll be more responsible for their own healthcare."

According to Bouchard, 26 patients were initially approached for the program and 12 of them accepted. "Out of those 12," she said, "we've had only one readmission. We're expecting to build up to as many as 10 people a week. Over the next two years, we are required to reduce hospital readmissions by 20 percent or our reimbursement agreement (for the program) will not be renewed."

Bouchard stressed that the program is not grant-based and has been set up as a reimbursable service.

Sue Amaral is a licensed social worker with specialized training in the transition program. She said her in-home clients have been very appreciative of the program. "It reiterates what they were told in the hospital at a time when they were too sick or too tired to remember the instructions. We do things like going through their medications and making sure they know what they're taking, and why they're taking it. Also, we talk about red flags - what to watch out for in terms of changes in their condition that might require contact with their doctor. The goal of this 30-day program is patient empowerment."

Since 2012, Obamacare has required all hospitals to be financially penalized for "preventable" readmissions. Kootenai Health CEO Jon Ness said that, to date, Kootenai hasn't had a single readmission in a targeted health category and that the facility's performance has exceeded required Medicare standards.

"The future of healthcare doesn't end at the hospital anymore," Ness said. "The hospital is now required to have stronger relations with community health programs. Currently, one of the biggest challenges of the patient hand-off (from hospital to home) has been medication errors. We need to help patients better manage their medications once they have left the hospital."

Kootenai Health is currently exploring the possibility of setting up a medication hotline for patients and caregivers to allow them convenient access to needed drug information.