Professional Geriatric Care Managers (PGCM) reduce avoidable hospital readmissions by filling gaps in the system with proper planning for care transitions and improved communication. 

Nearly one in five Medicare beneficiaries discharged from the hospital are readmitted within 30 days, and about one-third within 90 days. Up to 76% of these readmissions may be preventable (MedPAC, 2007).  Reducing these readmissions is better for the patient, the hospital and the American financial picture. 

5 Key Gaps Filled by Professional Geriatric Care Managers:

Keeping a Patient-Centered Perspective of the Team – Healthcare providers are overwhelmed with responsibilities having little to do with the patient.  Preventing lawsuits and understanding insurance coverage may take precedence over the wishes and needs of the patient.  A PGCM who has known and worked with the patient over time and in multiple settings can help keep the team focused on the individual’s needs and encourage outside-the-box problem solving.

Information Transfer– Because the PGCM is the only professional who follows the patient from home to the hospital, and everywhere in between, they are uniquely able to ensure information is available along the way.

Deciphering The Medical Maze – Most PGCMs have years of experience in the medical field and previously worked for a hospital or facility, so they speak the language and understand the rules.

Medication Management – According to www.cms.gov, 30% of patients have at least one medication discrepancy at discharge from the hospital.  1 in 5 patients discharged from the hospital experience an adverse event within three weeks of discharge; 60% were medication related and could have been avoided. PGCMs reconcile medications at each care transition and, when discharging from the hospital, go so far as to fill new prescriptions, setup a medication system in the home and monitor the system to be sure the client is successful.   

Follow-up Care – PGCMs help their clients follow discharge instructions, attend follow-up appointments, and communicate any problems back to the provider.

Editor’s Note: Article submitted by Gretchen Napier Geagan, MSHA, CMC, owner of Life-Links Geriatric Care Management. 615-595-8929 or www.life-links.org.