About one in five of those high-risk, most vulnerable patients are readmitted to a hospital within a month, according to the center.
The task force is seeking out the root causes of the readmissions. For example, a patient may be homeless and doesn't have access to healthcare services. Another may have a relapse, or a different health issue may arise while at a skilled nursing facility.
Another health issue somewhat unique to Glendale is its large foreign-born population. Some residents from other countries have not had access to health care, education or preventive care, Nelson said, which has resulted in delayed treatment or deferred chronic disease management.
Nelson said a major problem is that some high-risk patients don't see a doctor in the first week after release from the hospital.
Also, some patients don't have their medication prescriptions filled immediately after being discharged, Nelson added.
“Even going 12 to 18 hours without their medication could already put them on a trajectory for readmission,” Nelson said.
Hospitals are addressing those issues through their case managers, Nelson said, who can make sure high-risk patients schedule their first follow up doctor's appointment and have transportation to and from the physician's office.
Likewise, they can check to see that prescriptions are filled and that a patient has a ride to the pharmacy, as well as a way to pay for the medication.
Ascencia, the area's largest homeless services provider, is part of the task force and is working to see that high-risk homeless patients get a helping hand after they are discharged.
Local hospitals are identifying homeless patients who frequent the hospitals and coordinating with Ascencia to make sure their health needs — and living arrangements — are addressed, the nonprofit's executive director, Natalie Profant Komuro, said.
Skilled nursing facilities will be coming onboard to provide more information about what happens to high-risk patients they are treating, Nelson said.
Local hospitals have wanted to tackle the readmission issue for a while, he said, and now technology is making that easier to do.
The task force is also reaching out to local service organizations, such as the YMCA, YWCA, Catholic Charities, Armenian Relief Society and senior programs offered through the city to provide health and fitness programs for not just high-risk patients, but all discharged patients.