Reducing Readmission Rates through Care Management

When you get the call that mom or dad is coming home from the hospital, there are many difficult questions that flood your mind: Is he ready? Who will help take care of mom while she recovers? Is the house safe and ready for dad to come home to? Where do I start with finding help?

A Successful Transition Home

A transition home from the hospital begins with setting your loved one up for success and bringing quality healthcare to wherever they are, beyond the walls of the hospital. It may seem obvious, but a successful transition home also means not returning to the hospital shortly after discharge. Many families get caught in a cycle of hospital visits that is draining in every sense of the word for everyone involved. Introducing a Professional Geriatric Care Manager is one of the most important ways that you can reduce the risk of having to readmit into the hospital in a very short period of time and defuse the stress on you as a family caregivers. 

The Role of a Care Manager in a Successful Transition:

A Geriatric Care Manager is an RN or MSW who is an expert in eldercare. Here are just a few ways they bring about a successful transition home and reduce readmission rates.

A Geriatric Care Manager:  

  • Establishes and follows a care plan, ensuring the doctor’s orders are implemented and consistent
  • Coordinate and between primary care doctors, specialists, physical therapists, and family to ensure consistent communication and implementation of treatments and care.
  • Manages medications ensuring that proper drug dosages are taken and ordering prescription refills
  • Discharge and transition is coordinated and overseen by the care manager taking the burden off families
  • Discusses goals and wishes with the patient to ensure that their voice is heard, respected and supported during the process.
  • Advocates in the hospital ensuring that the patient’s wishes are respected and they receive the best possible care as defined by the individual.
  • Do an environmental inventory of the home to assess safety and make changes to the home to accommodate new needs.

In-Home Caregivers (Certified Nursing Assistant) form an elite team with Geriatric Care Managers to ensure day to day care and safety as they: 

  • Allow for continued care and recovery in the home with familiar surroundings, social interactions, and quality sleep.
  • Monitor conditions, symptoms, and behavior closely, noticing small changes, advocating, and ensuring they are addressed before they become larger problems.
  • Reduce the risk of falls during recovery by providing stand-by assistance with activities of daily living such as bathing and using the bathroom.
  • Encourage activities and companionship for an increased quality of life, which assists in the recovery process as well.

This proactive approach is an asset to the client and their family as this elite team turns stressful situations into manageable ones and works to ensure positive outcomes for the client. However, it is also a huge benefit to hospitals, as this level of care is reducing the rate at which patients are readmitted into the hospital, especially during those crucial first 30 days of leaving the hospital. According to the Center for Healthcare Quality & Payment Reform, “One of the best ways for communities to reduce healthcare costs quickly and improve patient care in the process is to implement initiatives to reduce hospital readmissions. Research studies and quality-reporting initiatives around the country show that 15-25% of people who are discharged from the hospital will be readmitted to the hospital within 30 days or less, and that many of these readmissions are preventable.” Sound Options has been providing quality care to families in the Puget Sound since 1989. It is our great privilege and passion to provide quality of life for aging loved ones and their families through Geriatric Care Management and In-Home Care, and Eldercare Coaching services. Click here to find out more about our services. 

Published on March 29, 2013.