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Preventing Unnecessary Hospital Readmissions

According to research reported in the New England Journal of Medicine, approximately one in five Medicare beneficiaries discharged from a hospital will end up back in the hospital within thirty days.  It usually is for the same reason they were admitted originally.  This means that it not only is bad for the patient who has to go back to the hospital, but it typically represents an expense that could have been avoided.  And it is these sorts of statistics that give me a chance to talk about a question I get asked a lot: “What is it that geriatric care managers do?”  Let me explain.

The typical picture of an older patient who is readmitted is one without a lot of social support locally, and this older patient:

  • May not fully understand their discharge instructions.
  • May not be taking their medications as instructed.
  • May have complications they cannot handle.

In most of these cases, if the patient had had someone to be the information processor, interpreter and implementer, the readmission would not have been necessary.  A geriatric care manager would be available to make sure the discharged patient understands any limitations on activity that the medical professionals have stipulated or understands how active they should be to recover from being in bed for the number of days they were in the hospital.  A care manager can help to make sure that all the patient’s medications are organized or that a new prescription gets filled and its dosing gets integrated into the daily regimen.  (Remember that seniors are about 13% of the population, but they represent about 30% of all the prescriptions written.

The National Transitions of Care Coalition offers a checklist your care manager or you as a caregiver can use with an elder for whom you are responsible as they leave the hospital:

  1. Have a method in place to assure safe use of all medications.
  2. Have a plan to facilitate the big change from hospital to home.
  3. Engage all members of the family and personal network of the patient.
  4. Share important information with all care providers and caregivers.
  5. Find and read any educational materials about the patient’s condition.
  6. Facilitate any follow-up provider visits, therapy, etc.

As a caregiver (or through your care manager) advocate for the patient to physicians, discharge planners or other providers responsible for the continuity patient’s care.

Charlotte Bishop is a Geriatric Care Manager and founder of Creative Case Management, certified professionals who are geriatric advocates, resources, counselors and friends to older adults and their families throughout metropolitan Chicago.  Please email your questions to Charlotte Bishop.


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