Winter 2011
Rehospitalization: How Care Managers Help Decrease Hospital Visits

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

About the Authors

Marisa Scala-Foley serves as a Social Science Analyst under the Office of Policy, Analysis and Development at the U.S. Administration on Aging (AoA), where she focuses on technical assistance and partnership building related to the Affordable Care Act. Prior to joining AoA, she served as Director of the AoA-funded National Center for Benefits Outreach and Enrollment at the National Council on Aging, and has worked her entire career in the field of aging on issues related to developing accessible educational materials and infrastructure for health-care and long-term care education (for consumers and professionals), consumer navigation of the U.S. health-care and long-term care systems, and consumer direction in long-term care for older adults. Marisa holds a Masters in Gerontological Studies from Miami University (Ohio), and a Bachelor’s degree in Sociology/Gerontology from the College of the Holy Cross in Worcester, MA.

Dr. Michelle Washko is a gerontologist with expertise in the area of productive aging, specifically around the issues of older workers, the eldercare workforce, and prevention. She came to the Administration on Aging from the U.S. Department of Labor, where she helped to administer Title V of the Older Americans Act, along with developing demonstration grant programs for older workers, and conducting analyses regarding the aging workforce. Previously, she served as a Senior Research Associate at the Institute for the Future of Aging Services, conducting applied research on the long term care workforce and service coordination in affordable senior housing.  She was also an adjunct professor in the Department of Psychology and an instructor to older learners in the Gerontology Institute at the University of Massachusetts Boston. Dr. Washko holds a PhD and a Masters degree in Gerontology from the University of Massachusetts, and a Masters degree in Individual & Family Studies from the University of Delaware. Along with her work, Dr. Washko actively publishes and is engaged in various professional organizations. Since 2000, she has held several appointed and elected positions in the Gerontological Society of America (GSA), and was one of the founding members of the International Council of Gerontological Student Organizations (ICGSO) in the International Association of Gerontology and Geriatrics (IAGG).

Caroline Ryan is an Aging Services Program Specialist in the Office of Program Innovation and Demonstration at the Administration on Aging. Caroline was previously employed by Aging Care Connections in La Grange, Illinois, where she implemented and evaluated a community-based service model that supported older adults and their families as they transitioned home from a community hospital and four skilled nursing facilities. In 2009, Caroline was selected as a Practice Change Fellow and designed a community-based program to support the transition home from the hospital for older adult observation patients and their families. Caroline received her undergraduate degree from Washington University in St. Louis and her Master’s degree and Certificate in Health Administration and Policy from The University of Chicago School of Social Service Administration.

Abigail Morgan is a Social Science Analyst with the U.S. Administration on Aging (AoA).  Within the Office of Policy, Analysis and Development, she focuses on resource development and providing technical assistance to organizations within the Aging Network related to Medicare and Medicaid program policies.   Prior to working at AoA, Abigail worked as a Program Manager at the National Association of Area Agencies on Aging where she focused on Medicare outreach and education, as well as capacity building, business practices and training for Area Agencies on Aging.  She has a Masters in Social Service and a Masters in Law and Social Policy from Bryn Mawr College.

Marisa Scala-Foley, MGS,
Michelle M. Washko, PhD,
Caroline Ryan, MA,
Abigail Morgan, MSS, MLSP


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).

Poor care transitions can result in medication errors, gaps in follow-up care, miscommunication, unnecessary rehospitalizations, and nursing home admissions (Jencks et al, 2009; American Geriatrics Society Health Care Systems Committee, 2007). A 2009 AARP survey of persons with chronic conditions found that 21 percent of those surveyed felt that their health care providers did not communicate well with each other – with 20 percent believing that this had had a negative impact on their health. Nearly 20 percent also cited a lack of coordination in their care transitions (AARP, 2009).

In addition to the medical factors associated with poor transitions, unmet needs in the community can impact the success of care transitions. Some studies have found that between 40 and 50 percent of readmissions may be due to social factors and a lack of access to community resources (Proctor et al, 2000). In a recent study evaluating the home food environment of hospital-discharged older adults, one-third of participants reported being unable to both shop and prepare meals after discharge (Anyanqu et al., 2011). Medicaid waiver program research also demonstrates that greater volume of attendant care, homemaking services, and home-delivered meals are associated with lower risk of hospital admissions (Xu et al, 2009).

Supporting care transitions needs to be a collaborative, community-based process that brings together professionals from all health-care related fields – including geriatric care management – to facilitate smooth transitions and prevent readmissions (Ventura et al, 2010). This article will discuss the role of geriatric care managers within care transition teams and common strategies implemented by care transitions programs to reduce avoidable hospital readmissions.

Care Transitions – Addressing the Problem

Transitional Care – defined by the American Geriatrics Society as “a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location” –   is designed to prevent unnecessary rehospitalizations and improve outcomes for older people (American Geriatrics Society Health Care Systems Committee, 2007). Evidence-based care transition models — including the Care Transitions Intervention (University of Colorado Denver, 2011), the Transitional Care Model (University of Pennsylvania School of Nursing, 2011), Better Outcomes for Older Adults through Safe Transitions, or BOOST (Society of Hospital Medicine, 2011) , Guided Care (Johns Hopkins University, 2011), Geriatric Resources for Assessment and Care of Elders, or GRACE (Counsell et al, 2006), the Bridge Program (Illinois Transitional Care Consortium, 2011), Project Re-Engineered Discharge, or RED (Boston University Medical Center, 2011), Interventions to Reduce Acute Care Transfers, or INTERACT (Florida Atlantic University, 2011), and more — have been developed to provide support to individuals and caregivers during and after the transition across hospital, skilled nursing facility, and community settings.

While the models may differ in terms of staffing, duration, and target setting, in most care transitions programs, individuals and caregivers at risk for poor transitions and hospital readmissions are identified and connected with designated care transition staff prior to discharge. Interdisciplinary communication and coordination as well as patient activation ensures that individuals and their caregivers understand post-discharge instructions regarding their medications and self-care, connect with outpatient physicians and other community services and supports post-discharge, and recognize and know how to respond to symptoms that may indicate potential complications.

Care Transitions and the Aging Network

In 1965, Congress enacted the Older Americans Act (OAA) to provide a broad range of coordinated services to older Americans which would enable them to maintain maximum independence as they increase in age. These services include nutrition programs, health promotion activities, ombudsman services in Long-Term Care settings, home- and community-based services, and caregiver support, to name a few. This legislation also created the AoA and the “Aging Network”—a national system with entities at the federal, state and territorial, tribal, and local levels. It includes 56 State Units on Aging, 629 Area Agencies on Aging (AAAs), 246 tribal organizations, some 20,000 local community service organizations, hundreds of thousands of volunteers, and a wide variety of national organizations, all of which work together to provide social services to older adults. State Units on Aging, which are state and territorial government agencies, administer, manage, design, and advocate for benefits, programs, and services.

More locally, Area Agencies on Aging provide a range of services that help individuals remain in their homes and communities for as long as possible. The Aging Network serves large numbers of older people and individuals with disabilities, including diverse populations and those with low incomes. Through this network, AoA reaches approximately 11 million individuals each year. The Aging Network receives not only the majority of AoA’s federal appropriation, but also funding from a variety of other sources (including the Centers for Medicare & Medicaid Services, or CMS, and the Department of Veterans Affairs, or VA) to deliver long-term services and supports. AoA is the only federal-level agency solely devoted to serving the social service needs of Americans aged 60 and over by means of programmatic activity. The Aging Network specifically targets services to the most vulnerable and frail elderly, and participants in Older Americans Act (OAA) services are more likely to be in poor health, need support for multiple Activities of Daily Living (ADLs) and more likely to be managing multiple chronic conditions (Kleinman and Foster, 2011; Altshuler and Schimmel, 2010). It is this target population that is most likely to be at risk for multiple hospital readmissions and can benefit from support during transitions across settings.

Supporting transitions across care settings has been an Aging Network activity for many years, and AoA and CMS have funded several initiatives related to improving the coordination of care transitions. Since AoA and CMS first began supporting the development of Aging and Disability Resource Centers (ADRC) in 2003, ADRCs have been working to assist individuals in “critical pathways,” defined as the times or places when people make important decisions about long-term supports and services . This work included several innovative community interventions to facilitate the hospital discharge process and help nursing facility residents return to the community. In 2009, AoA and CMS named “person-centered hospital discharge planning” as a key operational component of an ADRC and in 2010, 16 states were awarded funding to significantly strengthen the role of ADRCs in implementing evidence-based care transition programs (Administration on Aging, 2011).

Many care transition programs within the Aging Network are able to capitalize on existing infrastructure to implement evidence-based care transition strategies and provide increased access to critical long-term services and supports post-discharge. For example, community care transition staff from an ADRC or AAA not only provide options and access to transportation and remove barriers for attending physician appointments, but also empower and educate individuals on how to make the most of the appointment. Connection to community-based programs and services are especially important for individuals who need support beyond the short-term care transition program period which may also have the potential to impact frequency of readmissions (Proctor, 2000).

Care Transitions and the Current Role of Professional Geriatric Care Managers

Professional Geriatric Care Managers are important partners within local Aging Network initiatives and these community partnerships play a critical role within interdisciplinary care transitions teams. As members of care transition teams, it is helpful for professional Geriatric Care Managers (GCM) to understand effective care transitions strategies and how these strategies fit within their current professional roles and responsibilities.

Often the first transition that individuals experience within the health care system is the transition from the community to the hospital, and can provide important information to the hospital about the resources and supports that the individual and caregiver accessed prior to hospitalization. Community transition partners, including GCMs, have the unique ability to move across settings with the individual and caregiver, and the community is also frequently the last “receiver” post- discharge from healthcare settings. GCMs and community-based care transitions staff, such as AAA/ADRC staff, serve an important role in preparing the individual and caregiver for the next care setting through medication reconciliation, patient activation, an introduction to warning signs and symptoms, and development of a post-discharge follow up plan (Parry et al, 2003). Finally, successful transitions across care settings depend upon effective communication, incorporating multi-disciplinary team perspectives with sharing important client information and building a sense of shared accountability as individuals transition from one setting to another (Parry et al, 2003).

In terms of the current roles of GCMs, NAPGCM standards of practice relate well to the common elements of successful care transitions. Of particular note are the standards relating to the client relationship and professionalism of practice: (1) identifying the client, (2) promoting self-determination, (3) right to privacy, (4) definition of the role to other professionals, and (5) development of care plans (National Association of Professional Geriatric Care Managers, 2011).

  • Identifying the client. GCMs serve as client advocates and liaisons between various members of the client’s system, including family members, in-home aides, physicians and others (Kelsey & Laditka, 2007). This standard reinforces the concept of patient activation, where self-management of health and health decisions must include both the patient and family as part of the core health care team (Bodenheimer et al., 2002). This standard also relates to the theme of shared accountability and collaboration between providers in order to support a care transition. A GCM has the ability to examine the client system across care settings and collaborate with community partners to provide important insight to health care professionals whose perspective and influence may be limited to a particular setting.
  • Promoting self-determination. Core to this standard is the GCM identifying and articulating clients’ values and preferences in their care plans, regardless of the physical, mental or emotional capacity of the client (National Association of Professional Geriatric Care Managers, 2011). This standard can be most closely tied with the care transition theme of patient activation. Patient activation describes an individual’s ability to self-manage their own health, and personally engage in option development and decision-making processes (Hibbard et al, 2004). Rather than responding to presented care options, clients and family members should be full collaborators and developers of their own health goals to the maximum extent possible.
  • Right to privacy. The right to privacy needs to be maintained to the maximum extent possible, while fully disclosing the limits to confidentiality upfront to the client. Previous qualitative studies indicate that GCMs continue frequent contact with clients across various hospital, nursing home and home settings, and often act as patient advocates (Dobrish, 1987, Kelsey & Laditka, 2007). As such, GCMs can be integral members of an interdisciplinary care transitions team. Such a role may require additional considerations for disclosing patient or client information. Client populations that are at high risk of multiple readmissions will require upfront discussions and preparation of appropriate agreements (informed consent, release of information, etc.) for the GCM should they be hospitalized. Considerations can include:
    • How will a GCM be notified of a hospitalization
    • What role does the client wish the GCM to play during the hospitalization, and how will information about this role be conveyed to other members of the care transitions team, such as hospital, rehabilitation, or nursing facility staff.
    • Whether GCM will need business affiliate agreements with hospitals under HIPAA — or will hospital case management department consider a GCM a member of the core care team, therefore bypassing HIPAA requirements (Yang & Kombaracaran, 2006).
  • Definition of the role to other professionals. GCMs should clearly define their role and scope in terms of a client’s wishes and the GCM’s professional capacity (National Association of Professional Geriatric Care Managers, 2011). This standard most closely aligns with the critical theme of supporting multidisciplinary communication and shared accountability during a transition across the continuum of care. GCMs can serve as the bridge between actively engaged patient and family members and the professional health care team. In addition to providing perspective of clients across the continuum of care, GCMs bring an underrepresented expertise through their geriatric perspective and training to multidisciplinary teams in settings where trained gerontologists may be in short supply (Counsell et al, 2007). Yet involvement in a truly collaborative and interdisciplinary team process remains a difficult concept to incorporate into everyday practice (Netting & Williams, 1996). Geriatric care managers’ commitment to identifying the client and total client system provides an advantage in being able to view the sum of all parts at play, but can also put GCMs at odds with a sense of shared accountability as GCMs may see themselves as more accountable to clients than to a team of loosely connected health care professionals.
  • Development of plans of care. In terms of supporting a successful care transition, this standard closely relates to supporting follow-up care and medication management post-discharge, as well as developing care plans that support patient/client activation. After a discharge from a hospital, care plans often require adjustments. GCMs are well suited to inform the discharge process of clients’ existing care plans as well as community resources available to address new supportive service needs. GCMs also frequently accompany clients to physician appointments and help their clients make sure that important questions are addressed. GCMs can help identify poly-pharmacy issues, activate clients to address their medication questions with their follow-up primary care physicians, or make referrals to pharmacists for medication therapy management. However, specialized training and collaboration with other healthcare professionals is needed to fully address important medication reconciliation processes post-discharge (Rust and Davis, 2011).


Transitioning from one care setting to another can be potentially harmful for individuals with serious or complex illnesses, in part because the care transition process is prone to errors resulting from poor communication and coordination, inadequate care management or follow-up care, etc. In addition, poor care transitions are costly. Almost one in five Medicare patients (approximately 2.6 million older adults) are readmitted to the hospital within 30 days of their original discharge. This extrapolates to a cost of over $26 billion per year (U.S. Department of Health & Human Services, 2011). Successful and cost-effective care transitions require better connections between medical providers and community services providers. While there are roles for many different professionals to play in this process, geriatric care managers can clearly be part of a community-based solution.

Investing in geriatric care managers for care transitions

Given the new emphasis on care transitions in the Affordable Care Act and the rapid aging of our population, the need for an increased number of professionals well-versed and trained in care transition planning is more crucial than ever. Geriatric care managers are perfectly positioned in the Aging Network to fulfill this role, and many already do. Geriatric care managers can provide initial assessments, access to community services, care coordination, counseling, and family members support for clients who may not quality for increasingly stringent income requirements for public services (Dobrish, 1987, Kelsey & Laditka, 2007). However, according to a 2010 survey of Area Agencies on Aging Directors, only about 12.6 percent of AAAs employ certified geriatric care managers. Yet, in preparation for the current population age wave, AAAs foresee the need to invest within the next five years in additional case managers and expand staff qualifications to include certified geriatric care management within their case management units (Morgan, et al, 2010).

Geriatric care managers can play different roles in care transition planning within the Aging Network. First, they can be and are employed as transitional care staff. They can also be utilized as members of the interdisciplinary care transitions teams. Finally, they can serve as “community conveners,” pulling together all the appropriate medical and social service providers who relate to care transitions. This in turn improves connections for the patient and their family to the long-term services and supports system.

However, if geriatric care managers are to properly meet these kinds of job duties, it must be made sure that they receive appropriate skills training to help them meet the demands that will be asked of them. For example, geriatric care managers should consider how care transition strategies align with their existing professional roles and responsibilities, including patient activation, which requires empowering their patients/clients, as opposed to “doing” for them, and engaging in teach-back methods where the patient/client learns to advocate and act on their own behalf. Additionally, professional education programs for future care managers should specifically address breakdowns in the interdisciplinary team/collaborative processes. The soft skills of conflict resolution and problem-solving can help keep the lines of communication open, and if geriatric care managers are part of the bridge between the medical and community, these can help to keep the relationship functional and the care transition planning process moving. Finally, given the importance of medication reconciliation to the care transition process, additional training about this critical issue may be needed for GCMs – particularly who do not have a nursing background.

The problem of poor transitions has serious outcomes for patients, their families, and our health care system – one that needs collaborative, multidisciplinary, community-based solutions in order to provide high quality, more cost-effective care. The Aging Network and geriatric care managers can and will continue to play a critical role in reaching these aims.


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