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Winter 2011
Rehospitalization: How Care Managers Help Decrease Hospital Visits

Guest Editor’s Message – Hospital Readmissions

Cathy Jo Cress, MSW An estimated 90% of hospital readmissions take place within 30 days of discharge and are unintended. These readmissions, often avertable, cost Medicare $17.4 billion in 2004. The financial toll of avoidable read- missions is only one harmful effect on the U.S. health care system, now in the process of a major…

Do Geriatric Care Management Interventions Make a Difference? Prove It.

Deborah Newquist, PhD, MSW, CMC The environment within which geriatric care managers (GCMs) provide their services is undergoing a sea of change. Health care reform, embodied in the Affordable Care Act of 2010 (ACA), has catapulted the topic of chronic care into the forefront. Along with the cresting wave comes recognition of the need for…

Transitioning Care to the Home: Reducing Rehospitalization Among Frail Elders

Rona S. Bartelstone, LCSW, BCD, CMC, C-ASWCM There have been numerous studies in recent years that document the relatively high risk of rehospitalization among recently discharged, complex care Medicare beneficiaries. According to the 2009 Jencks article in the New England Journal of Medicine, one in five seniors are rehospitalized within 30 days of being discharged…

Evidence-Based Transitional Care for Chronically Ill Older Adults and Their Caregivers

M. Brian Bixby, MSN, CRNP Summary The Community-Based Care Transitions Program (CCTP) authorized by Section 3026 of the Affordable Care Act of 2010 aims to reduce hospital readmissions, test sustainable funding streams for care transition services, maintain or improve quality of care, and document measurable savings. A multidisciplinary research team developed the Transitional Care Model…

Helping Reduce Hospital Readmissions Using Seven Key Elements

Cathy Jo Cress, MSW Introduction This article discusses the elements of transition in care based on the National Transitions of Care Coalition’s evidence-based “Crosswalk” of transitions of care program. It documents how geriatric care managers can implement all seven transition elements, thus saving patients, aging families, the long-term care system, and hospitals money. It covers…

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