Keeping Clients Out of The Hospital – The Benefits of Enlisting an A Geriatric Care Manager

There are many reasons that a trip to the hospital is not a good idea these days.  To name a few COVID-19, payor reimbursement penalties if readmitted, and the increased risk for infection.  A Geriatric Care Manger is a resource to keep you well at home..

How many older adults, after a discharge from the hospital, end up back in the hospital shortly after?  20% of Medicare beneficiaries are readmitted to the hospital within 30 days of discharge.  That’s many.

Knowing that the first 30 days post discharge from the hospital puts you at risk for a return raises a red flag to a care manager.  Furthermore, if we look even closer at the statistics as they relate to hospital discharges, it can be noted that about 80% of re admissions that occurred within the first 30 days could have been prevented.   

A Geriatric Care Manager also known as a Aging Life Care Professional is a good resource to help keep an older adult at home.

  When a care manager learns that a patient is admitted, they contact go into advocate mode.  What do I mean by this you ask?  Let me explain, the care manager is trained to advocate and do whatever it takes to promote wellness and the highest level of independence.  With that said a great GCM will in this case get on the phone immediately with the case manager at the hospital. The GCM will begin immediately to advocate and plan for discharge.   This initial contact lays the groundwork for a successful discharge that lowers risk of readmission. The care manager will ask the hospital discharge planner several questions:

  • What’s the care plan?
  • What’s the expected length of hospitalization?
  • What kind of care will the patient need when they go home?
  • Does the patient need to be discharged to a facility other than home, such as a skilled nursing facility or a rehabilitation facility?
  • How will the hospital communicate the discharge plan to the patient, family, or caregiver?

Sounds easy enough right?  Wrong!  As critical as the above questions are, they are often not discussed with the patient or the patient does not remember what they were told. Consider that patients forget up to 80 percent of what health-care providers tell them—and what they do remember is wrong almost half the time, according to a 2003 study in the Journal of The Royal Society of Medicine. A real disaster for success. 

As hospital stays become shorter in duration, care is best coordinated when the older adult has an advocate. In the absence of local family or someone to do this a Geriatric Care Manager is a good choice and should absolutely be called into the playing field if the client can afford it.  The Geriatric Care Manager, becomes part of discharge planning, the GCM will communicate with the Primary Care Physician (PCP) and Hospital Discharge Planner to coordinate Home Care, make sure new prescriptions are written and picked up at the Pharmacy, that all DME arrives at the home prior etc…  The GCM will make sure that all follow up appointments and transportation to get there are arranged prior to discharge.   Sounds simple to you and I but you’d be surprised how much can go wrong.  Usually the only thing the patient cares about is getting back home the rest is just simple details that can be ironed out over time.  WRONG!   Timely coordination of care and communication is essential to preventing a readmission.

Once the older adult is at home the GCM will review the discharge summary and again make sure that all orders and follow up actions are scheduled. 

The final, crucial step in reducing the chance for hospitalization is having the patient and caregiver teach back the care plan. This is how the GCM confirms that the client has successfully educated the patient on their discharge plans, diagnosis, medication, and when to call their PCP.  Teach back confirms the patient’s understanding of the follow-up appointment with the PCP and instruction details. The GCM will give their client their number to call with any questions. Each step is intended to improve outcomes, mitigate cost, and to prevent gaps in care.  GCM’s make the difference a good resource is Careplan Geriatric Care Mangers providing telephonic and in-person care management locally and long-distance. 

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