Fixes looks at solutions to social problems and why they work.

If you’ve listened to the debate on how the United States should avoid going over the “fiscal cliff” over the past months, you might believe that the government has only two options to address its budget woes — either slash social programs, as conservatives favor, or the liberal tack, raise taxes. That’s a myopic view, one that actually distorts the relationship between social programs and society at large. Many of the most effective ones are not a mere expense to be trimmed off a budget; they often can and do save considerable money for society. And they’d be even more economical in this regard if the government invested in their widespread adoption.

Often, to save money you need to change systems or add new functions, not eliminate them.

One such example is the Transitional Care Model (TCM), which provides planning and home follow-up by trained nurses for chronically ill Medicare patients during and after hospitalization. The TCM illustrates a key point. Often, to save money you need to change systems, or add new functions, not just cut things.

The TCM was developed over the past two decades by the University of Pennsylvania School of Nursing to fill an urgent gap in our health system, one that is likely to be familiar to many readers: millions of chronically ill older patients (or their spouses, partners or children) are poorly prepared to take proper care of themselves or their loved ones after a hospital stay. (According to a recent report, there are more than 42 million unpaid family caregivers in the United States.)



Returning home after hospitalization for, say, heart failure or surgery, patients and their relatives are apt to be overwhelmed. Often there are complicated regimens of medications to follow (half of Medicare beneficiaries live with three chronic conditions and 20 percent live with five or more). Key information about a patient’s treatment may fail to be communicated to personal physicians or staff members at other care facilities, increasing the risk of error. If patients or relatives lack the ability to recognize warning signs of problems, they may ignore them or overreact and end up unnecessarily in the emergency room. They may be confused about how to access community services or safeguard the home to prevent accidents.

Because of things like this, more than a third of elderly patients discharged from hospitals in the United States are re-admitted within 90 days, often needlessly.

The Coalition for Evidence-Based Policy lists the Transitional Care Model in its ranks of programs that meet Congressional standards for “top-tier evidence.” The Coalition reports that studies of the TCM (conducted with different groups of chronically ill Medicare patients in different settings) showed that it reduces re-hospitalizations by 30 to 50 percent with no adverse effects, saving up to $4,000 per patient (after taking into account program costs), and reducing considerable distress for patients and their families. “These results suggest that successful national replication of this model could generate Medicare savings of about $10 billion per year — without cutting anyone’s benefits,” explains Jon Baron, the Coalition’s founder.

Mary Naylor, a professor at University of Pennsylvania School of Nursing who has researched the TCM extensively, observes that one of the ways that TCM succeeds is by acting proactively to “interrupt” things that could go wrong before they do. The same thinking extends to programs that successfully reduce the incidence of child abuse, high school dropouts, drug addiction or crime. When we cut these programs, we pay more later.

As they say in business, it takes money to make money. TCM’s nurses receive advanced training as primary care coordinators. They become skilled at engaging patients, family members, physicians and other community members. They make their first home visit usually within a day of discharge and continue for up to three months, during which time they may make dozens of visits, inquiries and phone calls on behalf of patients. “The nurses go into the home,” explains Naylor. “We go to their next site of care, we go to the first visit with their clinician, we work with them in their environment. We’re very deliberate at trying to understand all the challenges that people will face. Continuing the medical management this way is fundamental, but so often it doesn’t happen.” Anyone interested in decreasing Medicare costs should fight to get well-tested models like this added to the system.

There are numerous examples like TCM — with enough evidence to justify expansion and further study or widespread adoption. Many programs we have reported on in Fixes are potentially big budget savers. The Nurse Family Partnership has been shown to reduce child abuse and crime and improve long-term educational outcomes for children and mothers, saving more than it costs. (Researchers estimate that investments in effective early childhood education yield 8-to-1 returns for society.) The model of Housing First for chronically homeless people, employed by the 100,000 Homes Campaign, has been shown to save money, particularly from reduced hospitalizations. The family-based model developed by Youth Villages is effective and considerably less expensive than residential treatment for youths. Multidimensional Treatment Foster Care for severely delinquent youth has been shown to cut criminality and teenage pregnancies. The Washington State Institute for Public Policy calculates expected savings (pdf) from many well-tested social programs. Lawmakers making use of its recommendations have seen the state’s prison population grow far less than the national average.

Related More From The Stone Read previous contributions to this series.

TCM is an example of a program that our fragmented health system desperately needs. So why don’t we hear more about transitional care and less about, say, cutting PBS? “For a program like the Transitional Care Model,” notes Jon Baron, “even when there is a strong finding of effectiveness that’s been replicated, there’s usually not a mechanism within the federal government that facilitates widespread adoption — because the funding criteria [i.e., what Medicare will reimburse] does not prioritize that kind of evidence.”

As I reported last May, the Obama administration has promised to focus more on rigorous evidence in its 2014 budget. Indeed, many federal programs fail to show results when subjected to large rigorous evaluations. But while it’s easy for budget hawks to call for the axe, we have to remember that cutting a program doesn’t make the problem go away. We’ll still have people who are unemployed, unskilled, aging, chronically ill, disabled, living in substandard housing, and so forth. In many cases, their problems, if ignored, will become more costly for society over time.

Shifting the dynamic from an endless argument about tax revenues versus spending cuts, to a discussion about how to spur innovation and evaluate performance could help Congress act more responsibly. One tool that Baron advocates is for federal agencies to make more systematic use of waivers (pdf), giving states more leeway to try out new approaches – provided their experiments are coupled with rigorous evaluation.

This happened during the 1980s and 1990s, when many states experimented with modifications to federal welfare rules accompanied by rigorous studies to see if they actually helped people find employment and move out of poverty.

The evidence became central to the debate about how to reform welfare, recalled Howard Rolston, former director of the office of planning, research and evaluation in the Administration for Children and Families at the U.S. Department of Health and Human Services, who oversaw many of the welfare evaluations. “In such a political world, you can’t expect that research is going to be the dominant way that policy changes,” he said.

“But if you look at a lot of the welfare debates in Congress, people actually pulled out the research while they were speaking. The fact that in such an ideologically driven area the research penetrated and had an influence was impressive. It became more than just your anecdote versus my anecdote.”

In the end, the long term strength of any society hinges on whether its members are predominately healthy, law abiding and capable of working together and making meaningful contributions. If we stop nurturing and investing in credible fixes for these challenges, we really will go over a cliff.

David Bornstein is the author of “How to Change the World,” which has been published in 20 languages, and “The Price of a Dream: The Story of the Grameen Bank,” and is co-author of “Social Entrepreneurship: What Everyone Needs to Know.” He is the founder of dowser.org, a media site that reports on social innovation.