Preventing Hospital Readmission with Care Management

Hospital readmissions are getting increasing attention in the ever-changing landscape of health care and the implementation of the Affordable Care Act.   It is estimated that 1 in 5 people on Medicare are k7284870readmitted to the hospital within 30 days of discharge due to complications.  Readmissions can result when patients have a lack of understanding of discharge instructions, poor social support, lack of follow-up with primary care or specialist physicians, and changes to their medication.

The statistic being quoted most is that 45% of hospital readmissions among Medicare and Medicaid patients could have been prevented.   Trust me, no one involved wants to see the older adult in the hospital, and they certainly do not want to see them twice in the same month let alone the same year!

For many of these patients they mean well, but they’ve just been in the hospital.  It’s hard enough to get one’s self to the doctor or the pharmacy when you are living alone.  Often transportation options are limited or costly.  When you add in that these folks are older, likely sicker, and just eager to get home, you realize it’s not difficult to forget something here or there.

That’s where a Care Manager really steps in. Our role hopefully starts before the hospital stay.  This way we can meet the client at the hospital (or depending upon the circumstances take them there) and be prepared with all the information the doctors want-current medications, emergency contacts, latest health concerns, etc.  We continue to advocate on the client’s behalf, whether it be reminding the doctors, nurses and caregivers that they are allergic or had bad reactions to certain medications, or explaining to the staff why it’s better that they test the client at certain times.

While our clients are in the hospital, care managers keep the family and primary care doctor up-to-date on what’s happening.  If either have questions or concerns, we communicate these with the hospital staff to ensure continuity of care.

And when it’s time for our clients to go home, we help keep appointments, medications and therapy organized and managed in a way that the clients understand so there is less chance they’ll end up back in the hospital.  We often pick up prescriptions and ensure that the client and caregivers know when they are to be taken; alerting the primary doctor to any changes.  We then follow-up to make sure that they are taken as they should be and there are no issues.  If there are unanticipated issues we contact the primary care doctor.

If a follow-up appointment has to be scheduled, we help make it and escort the client to the appointment.  Our role at the follow-up is to help the client fill in any gaps for the doctor, but also to understand and ask questions about ongoing treatment.

Care managers are a resource to the client and family.  We translate instructions into everyday terms and use the benefit of our experience to help normalize the situation and anticipate future issues.  As clients have often told us, “you don’t know what you don’t know.”  But that’s what care managers are here for, to anticipate and help our clients overcome potential pitfalls and keep them out of the hospital and in the community that they call home.

And finally, most importantly, we are the voice of our clients.  Our first action is always to understand our client’s wishes and goals.  We then ensure that those wishes and goals remain the guiding factor of our work with the client, so that the client lives a quality life, however they define quality.

Christine Bitzer, LICSW, is the Assistant Director of Seabury Resources for Aging’s Care Management service.   Care managers work with older adults on an individual basis to advise them on a variety of issues and services; such as home care, transportation, medical/legal assistance and housing. Families are put at ease having a knowledgeable guide to provide recommendations and resources to meet their unique needs. This expertise can save families money and reduce stress and time away from work. Christine can be reached at (202) 364-0020 or email her at


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