For every five Medicare beneficiaries discharged from a U.S. hospital, one person returns for within a month.

Often, doctors and federal policymakers say, those people could have avoided that second trip to the hospital altogether if only they’d received good follow-up care.

Now, pressured by federal penalties for high readmissions, some California hospitals are revamping discharge procedures and assigning health coaches to monitor patients for up to a month after they’re disconnected from the hospitals’ high-tech monitors.

Training for recently discharged patients ranges from roll-play practice in calling a doctor to tutorials in fundamental skills such as how to keep track of medication schedules and prescriptions.

The change follows on a Medicare policy instituted as part of national healthcare reform.

Since last fall, Medicare has been reducing its payments to hospitals under a provision in the Affordable Care Act that seeks to improve the quality of care. For each hospital, federal authorities calculate an expected readmission rate, based on that facility’s mix of patients. Hospitals that exceed their expected rate can lose up to 1 percent of their regular Medicare payments. The maximum punishment will rise to 2 percent with the start of a new federal fiscal year in October and to 3 percent in the autumn of 2014.

Such a penalty can cost a hospital millions of dollars.

“I believe that Medicare made a good decision with this policy,” said Robert Wachter, a professor at the UC San Francisco Department of Medicine and an authority on health care quality.

“Up until recently, even in good hospitals, we focused really intently on making sure the patients got really good care in the hospital, but not very much on what happened after the patients left. I can tell you that at my own hospital, after this new policy came into effect we focused on our discharge policy and what happens after a patient leaves in a far more thoughtful and aggressive way than we did prior to this policy.”

But Tom Petersen, executive director of the Association of California Healthcare Districts, called the penalties unfair.

“Ultimately it comes down to whether the patient has the ability or the economic wherewithal to prevent the hospitalization,” he said. “It seems to me that the current system puts the hospital 100 percent at risk for a readmission at a time when they don’t have 100 percent of the ability to prevent the readmission.”

Wachter conceded that the system needs adjustment. Currently, some facilities serving low-income communities or with a high proportion of elderly, frail patients may be hit harder, he said.

Of the eight California institutions paying the maximum penalties this year, four Los Angeles-area hospitals serve such populations. They are Glendale Memorial Hospital and Health Center, Olympia Medical Center in Los Angeles, San Gabriel Valley Medical Center and Centinela Hospital Medical Center in Inglewood.

“We think our penalty is just sort of systemic, based on the community we serve,” said Centinela Hospital spokesman Steve Brand.

“We are the only hospital in our area, and so we get a lot of patients who are just overall generally sicker than the overall population in Los Angeles County.”

Still, by increasing follow-up for discharged patients, Centinela managed to decrease its readmission rate by at 7 to 10 percent in the first quarter of this year, Brand said.

Olympia CEO John Calderone said his staff starts thinking about a continuity of care even before the elderly, ailing people who comprise a significant share of Olympia’s patient population are admitted. Staff members now meet regularly with nursing home medical personnel to discuss residents’ health status, he said.

Jas Jones, Calderone’s quality director, said Olympia staffers also have started “teach-back” sessions, in which the instructor checks the patient’s comprehension by encouraging the patient to teach the information back to the provider. The strategy acknowledges and seeks to adapt to the fact that people often are distressed and confused at discharge, she said. To give patients time to process the information, teach-back typically begins two days before discharge, Jones said.

Hospitals elsewhere in the country have reported that teach-back reduces readmission by as much as 25 percent. Calderone said he’s optimistic, but the program is new enough at Olympia that he can’t yet cite specific figures. Complicating the analysis, if a patient were discharged at his facility and readmitted elsewhere, he might not know about it for months, Calderone said.

He said Olympia’s own research shows that the three conditions federal authorities are focusing on pneumonia, heart attack and congestive heart failure – present a challenge. In one survey, the hospital spoke to people who had recently been discharged after being treated for one of those conditions. Some 68 percent acknowledged that they hadn’t contacted their doctor or had failed to fill prescriptions.

That lead their health to decline fast, especially among people with congestive heart failure, Calderone said.

To improve post-discharge care, last year, Olympia formed the L.A. Mid-City Integrated Care Collaborative with Good Samaritan Hospital, St. Vincent Medical Center, 14 skilled nursing facilities and rehabilitation centers, and an array of government and non-profit agencies that serve the elderly.

Under that program, Jewish Family Service caseworkers help patients complete health record forms that include the names and contact information for the person’s doctor and pharmacy, as well as a calendar for medical appointments and medication schedule.

“The idea is to have the client articulate and understand what their condition is, what the medication is, what it’s for, and as they have questions, to write them down, so that when they go to the doctor, they have a way of not forgetting and bringing it all together,” said Eli Veitzer, director of strategic initiatives and business development at Jewish Family Service of Los Angeles.

Social workers generally meet with patients before discharge, or at least reach them by telephone before they leave the hospital, he said. There’s a follow up-visit within three days of the person’s release.

Preliminary findings show those simple steps reduced readmission rates by 25 percent among congestive heart failure patients, Veitzer said.

Last month, AltaMed Health Services launched a similar health record and monitoring system in partnership with Hollywood Presbyterian and White Memorial medical centers.

Anthony Ridley, AltaMed’s supervisor of case management, said the program includes a pre-discharge meeting, a home visit after the patient gets out of the hospital and at least three follow-up calls in the next month.

Those contacts are scheduled to coincide with important events, such as a patient’s first post-discharge doctor’s appointment or a meeting to set up a service such as Meals on Wheels. For patients unused to talking to physicians about their health, the service sometimes includes role-playing practice sessions.

Health coaches also teach people to watch for warning signs. For instance, an instructor might show a heart-failure patient how to track fluctuations in body weight, since even a small but rapid weight gain could be a red flag indicating congestive heart failure, Ridley said.

Wachter hopes proposed new fee schedules under health care reform also will help reduce readmissions further.

“There’s all kinds of experimentation with new models that pay the system — which includes the hospital and the doctor who will take care of the patient afterwards — a single fee, either for 60 days or maybe for a year of the care of those patients, and those kinds of models create those kinds of linkages that we need,” he said.