VOLUME 21 ISSUE 2 WINTER 2011 Published by the National Association of Professional Geriatric Care of Managers 3275 West Ina Road Suite 130 Tucson, Arizona Geriatric Care Management 85741 520.881.8008 / phone 520.325.7925 / fax www.caremanager.org Rehospitalization: How Care Managers Help Decrease Hospital Visits Guest Editor’s Message ......................................................................................................2 By Cathy Jo Cress, MSW Bridging the Gap: The Role of Geriatric Care Managers in Reducing Avoidable Hospital Readmissions ........................................................................3 by Marisa Scala-Foley, MGS, Michelle M. Washko, PhD, Caroline Ryan, MA, Abigail Morgan, MSS, MLSP Do Geriatric Care Management Interventions Make a Difference? Prove It. ....................10 by Deborah Newquist, PhD, MSW, CMC Transitioning Care to the Home: Reducing Rehospitalization Among Frail Elders .............13 By Rona Bartlestone, LCSW, BCD, CMC, C-ASWCM Evidence-Based Transitional Care for Chronically Ill Older Adults and Their Caregivers ..20 By M. Brian Bixby, MSN, CRNP Helping Reduce Hospital Readmissions Using Seven Key Elements ................................25 By Cathy Jo Cress, MSW Reducing Hospital Readmissions— One Hospital’s Journey to Implement Safer Transitions in Care ........................................29 By Robin Jones, RN of Geriatric Care Management Winter 2011 Guest Editor’s Message By Cathy Jo Cress, MSW An estimated 90% of hospital tion. The hunt for ways to improve and hospitals by becoming a part of the readmissions take place within 30 health care for older persons with LTC and transition in care system and days of discharge and are unintended. chronic illnesses put the spotlight the hospital-to-home team. They can do These readmissions, often avertable, on areas where care is deficient and this providing the necessary coaching cost Medicare $17.4 billion in 2004. costly. Transitions of care (TOC) are and support to patients and their fami- The financial toll of avoidable read- one such segment of the health care lies so that older clients are not readmit- missions is only one harmful effect experience. ted, and stay in the community, thereby on the U.S. health care system, now For years GCMs have provided reducing health care system expenses. in the process of a major reinvention. services to their clients during transi- This issue of the Winter Geriatric The human cost of repeated disease tions of care. Routinely moving Care Management Journal contains can be equally damaging in terms of clients from home to hospital to re- articles that show recent studies and re- the corrosion in function, reduced habilitation and back home, or to al- search on transitions in care and demon- symptom-free days, and loss of faith ternative living arrangements, GCMs strates how geriatric care managers can in a health care system previously have advocated for their clients. By be part of that home team and actually trusted to preserve or improve health. transmitting and reconciling medica- prevent hospital admission while doing Health care errors and adverse events tions and other information from one their regular job. That job is using the often associated with transitions in provider to another; counseling and continuum of care to keep older clients care only swell national discontent and educating clients and their families at the safest level of care. growing very public distrust in our about health conditions; navigating I want to thank the following poorly performing system. warped systems and coordinating authors for creating a new dimension Health care reform, exemplified services to meet changing client need, to the dialogue and call for action for by the Affordable Care Act of 2010 GCMs are experts in spotting the GCMs: Robin Jones, Marisa Scala- (ACA), propels the topic of chronic gaps and filling them. Foley, Michelle Washko, Caroline Ryan, care into the forefront and speaks for Geriatric care managers can help Abigail Morgan, M. Brian Bixby, Debo- the need to mandate care coordina- the long-term care system, doctors, rah Newquist, and Rona Bartlestone. EDITORIAL BOARD Rona Bartelstone, LCSW Fort Lauderdale, FL Cathy Cress, MSW Santa Cruz, CA Lenard W. Kaye, PhD Orono, ME of Leonie Nowitz, MSW, LICSW New York, NY Journal Emily Saltz, MSW, LICSW Newton, MA Geriatric Care Management Monika White, PhD Santa Monica, CA Published by the: National Association of Professional Geriatric Care Managers EDITOR-IN-CHIEF 3275 West Ina Road, Suite 130, Tucson, Arizona 85741 • www.caremanager.org Karen Knutson MSN, MBA, RN © Copyright 2011 Charlotte, NC The Journal of Geriatric Care Management is published two times per year as a membership benefit to GRAPHIC members of the National Association of Professional Geratric Care Managers. Non-members may subscribe DESIGN to Journal of Geriatric Care Management for $95.00 per year. Send a check for your one-year subscription to: HagerDesigns Subscription Department, NAPGCM, 3275 West Ina Road, Suite 130, Tucson, Arizona 85741. Dallas, Texas PAGE 2 of Winter 2011 Geriatric Care Management Bridging the Gap: The Role of Geriatric Care Managers in Reducing Avoidable Hospital Readmissions By Marisa Scala-Foley, MGS, Michelle M. Washko, PhD, Caroline Ryan, MA, Abigail Morgan, MSS, MLSP Summary establishes the Community- based Care Transition Avoidable hospital Nearly one in five Medicare Program, which provides readmissions have received scrutiny due to their link beneficiaries discharged from the funding to community-based organizations and hospitals with poor quality health hospital are readmitted within 30 outcomes and high care that “furnish improved care costs. Two provisions days, and about one-third within transition services to high- of the Patient Protection 90 days, and up to 76 percent risk Medicare beneficiaries” and Affordable Care Act (H.R. 3590, 2010). The specifically target avoidable of these readmissions may be Community-based Care hospital readmissions, one preventable (MedPAC, 2007). Transition Program is of which focuses on care part of a companion effort transitions -- the movement undertaken by the U.S. of patients between health Department of Health and care practitioners and settings as 90 days, and up to 76 percent of these Human Services called the Partnership their condition and care needs change readmissions may be preventable for Patients. One of the two major during an illness. Proper planning (MedPAC, 2007). Such unwanted goals of the Partnership is to “help offers a proven way to prevent hospital readmissions have high patients heal without complication,” rehospitalizations and improve costs – both financially, for health aiming for a 20 percent reduction in outcomes for patients. This article care payment systems, as well as hospital readmissions by the end of discusses the role of geriatric care physically and emotionally for people 2013 (U.S. Department of Health & managers within care transition with Medicare and their families. In Human Services, 2011). teams and strategies implemented by 2004, Medicare spent $17.4 billion care transitions programs to reduce in hospital payments on unplanned Readmissions and Care avoidable hospital readmissions. readmissions (Jencks, 2009). Transitions The 2010 Patient Protection Care transitions are defined Introduction and Affordable Care Act (ACA) as “the movement patients make Viewed as an indicator of poor has a three-part aim of better between health care practitioners and quality and high cost, the problem of care for individuals, improved settings as their condition and care avoidable hospital readmissions has population health, and lower costs. needs change during the course of a received increasing scrutiny in recent While numerous provisions of the chronic or acute illness” (University years, with policymakers, payers, ACA seek to foster improved care of Colorado Denver, 2011). Such health systems, health and long-term coordination for Medicare and transitions might include going from supports and services providers, Medicaid beneficiaries, two provisions a hospital or skilled nursing facility and community-based organizations specifically target avoidable hospital to home, from a hospital to a skilled alike working toward reducing readmissions, albeit in different nursing facility, from one level of rehospitalizations (MedPAC, 2007; ways. Section 3025 authorizes the care to another (e.g., from a surgical MedPAC, 2008). Nearly one in five Secretary of Health and Human unit to an intensive care unit within Medicare beneficiaries discharged Services to reduce Medicare payments a hospital), or even from one form of from the hospital are readmitted within to hospitals with higher-than-expected 30 days, and about one-third within readmission rates, and Section 3026 continued on page 4 PAGE 3 of Geriatric Care Management Winter 2011 Bridging the Gap: The Role Care Transitions— Care Transitions and the of Geriatric Care Managers Addressing the Problem Aging Network in Reducing Avoidable Hospital Readmissions Transitional Care – defined by In 1965, Congress enacted the the American Geriatrics Society as Older Americans Act (OAA) to continued from page 3 “a set of actions designed to ensure provide a broad range of coordinated payment to another (e.g., from private the coordination and continuity services to older Americans which pay to a Medicaid waiver). of health care as patients transfer would enable them to maintain between different locations or Poor care