| Geriatric Care Managers Lead Highly Skilled Teams |  |
| Geriatric Care Managers Lead Highly Skilled Teams | |
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Rehospitalizations: Preventable and Costly |
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by Rona S. Bartelstone, LCSW, BCD, CMC, C-ASWCMDid you know that almost 20% of people on Medicare are rehospitalized within 30 days of a hospital discharge? And 60 days post-discharge almost 30% of this same population are readmitted to the hospital. (Jencks, Stephen F, et.al. NEJM 360;14. April 2009) These are huge numbers and should pose a concern to physicians and family caregivers. For older adults, being in the hospital is often a risk itself. There are risks of infection, risks of changes in mental status (especially if there is already some cognitive changes), and concerns for family caregivers, who themselves are older, or missing work to care for their loved one. In the same study cited above, it was also discovered that 50% of the patients who were readmitted to the hospital within 30 days, had not seen an outpatient physician. This raises further concerns about the ability of people over the age of 65 (hence Medicare eligible) to self direct their care and assure compliance with hospital discharge plans, which usually call for follow up with a primary or specialty physician. This is not to say that people over the age of 65 are not reliable for their own care. Instead, these statistics mean that the health care system needs to do a better job in following older patients across transitions of care. The very fact of being hospitalized creates a loss of energy, concentration and even emotional trauma. Recovery often takes longer as we age. Challenges to meet everyday demands can seem insurmountable. Getting back to the doctor may not seem as important as getting groceries, medications, therapy and rest. Additionally, in some areas of the country, just getting an appointment with one’s doctor can take a month. With health care reform on the horizon, hospitals will need to consider improved relationships with those community-based organizations that provide long term care in the home setting. Most hospitals have relationships with Medicare Certified Home Health Agencies. What most people don’t realize is that Medicare does not pay for long-term care. So when a Medicare agency is recommended, patients, families and caregivers need to realize that this is time limited care only. Usually Medicare home care is only provided for several weeks. Then what happens? For people who need care on a more continuous basis, the most typical level of care is for someone who is there to provide safety, medication reminders, assistance with bathing, dressing and toileting. These people often need help with things such as shopping, meal preparation, errands and doctor appointments, as well. Additionally, older adults often need emotional support to cope with their changes in function and an advocate to assure that they do get the follow up care that is so critical to recovery, without rehospitalization. This is part of the reason that SeniorBridge Care Managers work in teams. It is helpful to have staff who have expertise in a diverse array of care needs. So that while one Care Manager might have greater expertise in the medication, treatment and therapeutic aspects of recovery, the other will be focusing on the emotional needs of the patient and family, while making follow up appointments for the patient. Preventable rehospitalizations will not only make life more comfortable for the older adult and their family, it will also save millions in unnecessary Medicare expenditures. Perhaps those exploring health care reform should take a look at the SeniorBridge model of care across the continuum. |
About SeniorBridge
Why put the care of your loved ones with SeniorBridge? Our company’s unique approach addresses the total well-being of clients and their families through a comprehensive program that includes assessment, planning, service coordination, advocacy, and direct care by an interdisciplinary team led by a geriatric care manager. Read More About Us |
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