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More than 1 million Americans wind up back in the hospital only weeks after they left for reasons that could have been prevented – a revolving door that for years as seemed impossible to slow.

Now Medicare has begun punishing hospitals with hefty fines if they have too many readmissions, and a top official says signs of improvement are beginning to emerge.

“We’re at a very promising moment,” Medicare deputy administrator Jonathan Blum told the Associated Press.

Nearly 1 in 5 Medicare patients is hospitalized again within a month of going home, and many of those return trips could have been avoided. But readmissions can happen at any age, not just with the over-65 crowd who are counted most closely.

Where you live makes a difference, according to new research that shows how much room for improvement there really is. In parts of Utah, your chances of being rehospitalized are much lower than in areas of New York or New Jersey, says a new report from the Dartmouth Atlas of Health Care.

The AP teamed with the Robert Wood Johnson Foundation to explore, through the eyes of patients, the myriad roadblocks to recovery that make it so difficult to trim unneeded readmissions. The hurdles start as patients walk out the door.

“Scared to go home,” is what Eric Davis, 51, remembers most as he left a Washington hospital, newly diagnosed with a dangerous lung disease. His instructions: stop smoking. He didn’t know how to use his inhaler or if it was safe to exercise, until a second hospitalization weeks later.

There is no single solution. But what’s clear is that hospitals will have to reach well outside their own walls if they’re to make a dent in readmissions. Otherwise a slew of at-home difficulties – confusion about what pills to take, no ride to the drugstore to fill prescriptions, not being able to get a post-hospital check-up in time to spot complications – will keep sending people back.

“This is a team sport,” says readmissions expert Dr. Eric Coleman of the University of Colorado in Denver.The Robert Wood Johnson Foundation this week begins an effort called “Care About Your Care,” which offers consumers tips to guard against unnecessary readmissions. “Everyone has to understand their role in improving the quality of care, including families,” said Dr. Risa Lavizzo-Mourey, the foundation’s president.

Rehospitalizations are miserable for patients, and a huge cost – more than $17 billion a year in avoidable Medicare bills alone – for a nation struggling with the price of health care.

Yale University researchers recently reported in the Journal of the American Medical Association that people face a period of overall vulnerability to illness right after a hospitalization, because of weakness, sleep deprivation, loss of appetite and side effects of new medications.

But ask returning patients what went wrong, and Coleman said nonmedical challenges top the list.

New York’s Montefiore Medical Center now sends uninsured patients home with two weeks’ worth of medication so they don’t have to hunt an affordable place to fill a prescription, said Dr. Ricardo Bello, a cardiac surgeon.

In the nation’s capital, Dr. Kim Bullock recalled her frustration with a diabetic hospitalized nine times in one year in part because of transportation. He felt too lousy to ride two buses and the subway to the nearest Medicaid clinic for regular care.

The Dartmouth study found fewer than half of patients saw a primary care doctor within two weeks of leaving the hospital.

Barbara McCoy tried. A New York hospital lowered the 44-year-old diabetic’s dangerously high blood sugar and told her to call her own doctor immediately about how to prevent a recurrence. But she couldn’t get an appointment until the following month. A week later, her blood sugar soared again, and she raced back to the emergency room.

This time, the hospital pulled out the stops during a weeklong stay. A nutritionist offered intense diet advice. An endocrinologist changed her medications. She was taught how to safely adjust her own insulin. “Why couldn’t they have done all that the first time?,” McCoy said. “I don’t understand.”