Bridging the Gap: The Role of Geriatric Care Managers in Reducing Avoidable Hospital Readmissions


Avoidable hospital readmissions have received scrutiny due to their link with poor quality health outcomes and high care costs. Two provisions of the Patient Protection and Affordable Care Act specifically target avoidable hospital readmissions, one of which focuses on care transitions — the movement of patients between health care practitioners and settings as their condition and care needs change during an illness. Proper planning offers a proven way to prevent rehospitalizations and improve outcomes for patients. This article discusses the role of geriatric care managers within care transition teams and strategies implemented by care transitions programs to reduce avoidable hospital readmissions.


Viewed as an indicator of poor quality and high cost, the problem of avoidable hospital readmissions has received increasing scrutiny in recent years, with policymakers, payers, health systems, health and long-term supports and services providers, and community-based organizations alike working toward reducing rehospitalizations (MedPAC, 2007; MedPAC, 2008). Nearly one in five Medicare beneficiaries discharged from the hospital are readmitted within 30 days, and about one-third within 90 days, and up to 76 percent of these readmissions may be preventable (MedPAC, 2007). Such unwanted hospital readmissions have high costs – both financially, for health care payment systems, as well as physically and emotionally for people with Medicare and their families. In 2004, Medicare spent $17.4 billion in hospital payments on unplanned readmissions (Jencks, 2009).

The 2010 Patient Protection and Affordable Care Act (ACA) has a three-part aim of better care for individuals, improved population health, and lower costs. While numerous provisions of the ACA seek to foster improved care coordination for Medicare and Medicaid beneficiaries, two provisions specifically target avoidable hospital readmissions, albeit in different ways. Section 3025 authorizes the Secretary of Health and Human Services to reduce Medicare payments to hospitals with higher-than-expected readmission rates, and Section 3026 establishes the Community-based Care Transition Program, which provides funding to community-based organizations and hospitals that “furnish improved care transition services to high-risk Medicare beneficiaries” (H.R. 3590, 2010). The Community-based Care Transition Program is part of a companion effort undertaken by the U.S. Department of Health and Human Services called the Partnership for Patients. One of the two major goals of the Partnership is to “help patients heal without complication,” aiming for a 20 percent reduction in hospital readmissions by the end of 2013 (U.S. Department of Health & Human Services, 2011).

Readmissions and Care Transitions

Care transitions are defined as “the movement patients make between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness” (University of Colorado Denver, 2011). Such transitions might include going from a hospital or skilled nursing facility to home, from a hospital to a skilled nursing facility, from one level of care to another (e.g., from a surgical unit to an intensive care unit within a hospital), or even from one form of payment to another (e.g., from private pay to a Medicaid waiver).

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Advocare Care Advocates provide Medical Care Management to South Florida area seniors to ensure that patients get the follow up support they need to avoid readmissions to the hospital. To learn more, call us anytime at 561-266-3489. 


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