A recent study found that almost 20% of Medicare recipients who were discharged from hospitals were readmitted within one month of discharge.  Half of these patients did not see a physician in the month after discharge.  Further, the study found that 30% of Medicare recipients were readmitted within 90 days of discharge. The authors estimated that 10% of readmission were planned to follow up with treatment.  This high rate of unscheduled readmissions cost 17.4 billion dollars in 2004.

Re-hospitalization is stressful for patients as well.
The main reason cited for this high level of readmission was inadequate discharge planning.  This included failure to ensure that patients understood exactly how to take their medications, inadequate teaching about how to care for themselves at home, lack of home care equipment and nursing care, and inadequate follow up with primary physicians.

As decreasing reimbursement has squeezed hospitals financially, discharge planners have become a thing of the past.  Hospital social workers and nurses care for large numbers of patients and do not have the time to provide the discharge planning services essential for successful discharge.  Hospitals ensure, through a process called utilization review, that patients are discharged as quickly as possible.  This maximizes reimbursement to hospitals but often leaves patients vulnerable to complications requiring readmission.

Geriatric Care Managers are valuable professionals who can ensure that proper and effective discharge planning occurs when patients are hospitalized.  Care Managers are knowledgeable about discharge needs and will make certain that essential home health care services and home medical equipment is arranged prior to discharge. Reviewing discharge medications and putting a medication administration system into place avoids medication errors that often result in complications and readmission.

And the Care Manager will ensure that patients see their treating physicians in a timely manner after discharge to ensure that the treatment plan is effective.  Matrix AdvoCare Network has provided discharge planning services for over 22 years.  If you have a client who is hospitalized or has a surgical procedure planned, please call 952-525-0505 for a complimentary discussion about your client’s anticipated needs.

Jencks, S.F., M.D., M.P.H.; Williams, M.V., M.D; and Coleman, E.N., M.D., M.P.H. Rehospitalizations among Patients in the Medicare Fee-for-Service Program.

New England Journal of Medicine, Volume 360:1418-1428. April 2, 2009, Number 14. Matrix AdvoCare NetworkMatrix Team Home Care952-525-0505www.matrixadvocare.com