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 how GCMs can help prevent
unnecessary hospital readmissions, implement Medicare savings, and ensure adequate follow-up care.

CMS 2012-2013 Penalty for 30-Day Hospital Readmissions

The centers for Medicare and Medicaid Service (CMS), a branch of the U.S. Department of Health and Human Services, will penalize doctors and hospitals that have high 30 day readmissions rates in FFY 2013.

A recent study in the New England Journal of Medicine demonstrated that within a month of discharge, over 20 percent of Medicare beneficiaries were rehospitalized for the same condition they had been treated for earlier. This is very costly for Medicare and U.S. taxpayers. The NEJM article suggests that patients are being released, before they are fully stabilized, to a home situation unable to cope with the demands of their serious condition. The penalty is designed as an incentive to be sure patients are being discharged responsibly with adequate follow-up care.

Geriatric Care Managers Can Be an Integral Part of the Long-Term Care System

Geriatric care managers can become an essential part of the long-term care system and the hospital-to-home team. That team can provide the necessary coaching and support to patients and
their families so that patients are not readmitted, stay in the community, and save everyone money.

To make this difficult transition successful and support the family caregiver, geriatric care managers
should have a significant role with families and elderly patients before, during, and especially after discharge from the hospital.

The role of the geriatric care manager with an elderly client in the hospital mirrors care management
tasks in general: educate, assess, advocate, move the client through the continuum of care smoothly, and coordinate care.

All these skills are needed during hospitalization but are critical before admission and at discharge. The geriatric care manager coordinates transitional care. Yet so often, because of hospital policy, geriatric care management is not implemented in the hospital or when patient and family transition to home, thus contributing to unnecessary readmission (Cress, 2009).

Discharge planners, usually nurses and social workers, are overwhelmed by heavy case loads, so they do not have time to give individual service to patients. Skilled GCMs can render highly individualized service, 24/7, making the discharge planner's job easier.

Seven Tasks That GCMs Can Perform to Prevent Readmissions

National Transitions of Care Coalition put together and evidence based "Crosswalk" of seven key elements of a transition of care program based on transition intervention research.

TASK 1:
Medication Management - A method to ensure the safe use of medications by patients and their families, based on patients' plans of care

The first task the GCM does before hospitalization is to update routine risk assessments, including depression screening, home safety, psychosocial and functional assessment, and current
medications, which GCMs routinely do with new clients. This medication risk assessment is then integrated into the patient's updated care plan before hospitalization. The GCM can then share this information with hospital staff at admission with the patient's and other providers' permissions, in a HIPAA-compliant environment.

The GCM can transfer medication information to a computer disc or
USB drive and give it to the hospital admissions department and family director, under HIPPA compliance. At discharge the GCM updates the medication list. The GCM ensures that the patient has a realistic plan for getting the medications and can pick them up if necessary to make sure the
patient has them.

For families who wish the GCM to provide a high level of support, this is an excellent way to educate
the patient's family at any transition of care, especially at discharge, when meds are often changed. The GCM counsels the family about medications, explaining what medications are being taken, emphasizing any changes in the regimen, and reviewing each medication's purpose, how to take each medication correctly, and important side effects to watch for.

TASK 2:
Transition Planning - A formal process that facilitates the safe transition of patients from one care setting to another, or from one practitioner to another

A GCM's job is to do transitions planning. Transition from one setting to another, especially into and out of the hospital, can be perilous for older people and their families. The change in surroundings, new providers, and new medications can be very disorienting. The patient often cannot speak for him or herself. The family often lacks some degree of health literacy and might not be included
in the plan of care. This, coupled with hospital understaffing, makes the GCM valuable in making sure transitions are planned and executed.

The initial full assessment and care plan that the GCM creates can be shared with the hospital doctor and all care professionals throughout hospitalization. The GCM can also assess the family caregiver and identify skill level and training needs, so that at discharge there is a workable
transition plan coordinated with the discharge planner, home health agency, and the health care provider team.

Before discharge, the GCM can alert hospital discharge planners to problems in the patient's home
environment such as lack of grab bars, loose wires, or steps. The GCM can solve problems before discharge, greasing the wheels of the transition through the home safety assessment.

The GCM can also refer families to the hospital social worker for additional support and access to services in the hospital. This helps the family be more prepared to take on the care, post discharge, increasing the chances that the patient will not cycle back into the hospital within 30 days.

TASK 3:
Patient and Family Engagement/Education - Family meetings in the hospital

Embracing a family centered perspective is critical to achieving quality of care and engagement for
people with chronic or disabling conditions. This perspective helps the GCM, along with the hospital staff and others on the health care team, successfully engage and organize the patient, family caregivers, and friends through all transitions. At the transition from home to hospital admission, the GCM can be a valuable conduit of information to the discharge planner, physician, and rehab or home health agency about the family and the level of dysfunction that will affect a transition to home.

Because of the ongoing relationship, the GCM can distinguish who represents the patient's family,
who will be caregivers, who will be the main spokesperson communicating with the discharge planner and others. If the client does not have mental capacity, the GCM can smooth the transition to home by organizing the family around this spokesperson.

To further engage the family, the GCM can arrange a family meeting in the hospital. Family communication can break down in the hospital, especially for dysfunctional families. The GCM can ask the hospital staff and attending physician to schedule a family conference. A plan of care
should come out of the meeting, which the GCM will create and submit to the family and the attending physician for consideration. The GCM can help the family add an ongoing list of questions
they wish to ask staff about regarding care, procedures, and problems.

The GCM can assist the family with health literacy. This can include condition-specific information in multimedia formats (print, DVD, discs, internet sites, and so on).

The GCM can interpret and enhance the health information given to the family about hospital procedures and the post-acute care that will be needed for a successful transition to home.

TASK 4:
Information Transfer - Sharing of important care information among patient family, caregiver, and health care providers in a timely and effective manner

The GCM always shares patient care information across the continuum of care in a timely and effective manner. The GCM can give a copy of the disc or USB drive with the patient's health record to the hospital admissions and family director, under HIPPA compliance, to ensure
that updated patient information is transferred and shared at every transition. The personal health record can include a copy the GCM's client data sheet with meds, diagnosis and care plan, and medical history.

Throughout the hospital stay, the geriatric care manager encourages the family to use the personal health record. This record can be managed with the GCM's support and helps to formulate the patient's and family caregiver's questions. These questions may include reasons for taking
medications, reason for a worsening condition, and problems in the hospital. This helps the family to share clear information with the hospital and to collect shared information from hospital providers.

A personal health record can be as simple as a piece of paper in a file folder. GCMs can encourage the family to transfer the information to a computer disc or USB drive, and there are many personal care record products and programs on the market.

The GCM shares the critical legal documents and care information with the hospital admissions (with
HIPAA compliance), such as power of attorney for health care, durable power of attorney for health care, a living will, or a do not resuscitate order. The GCM gets this information at intake, before a medical crisis and hospitalization occur. This legal information, already checked and shared, helps the hospital and ensures that the kind of care the older patient wants delivered is delivered.

TASK 5:
Follow-Up Care - Facilitating the safe transition of patients from one care setting or care provider to another through effective follow-up activities

The GCM's family-centered approach ensures safe transitions, especially at discharge, and effective
follow-up activities. The GCM helps organize the family into a unit of care to help with all transitions.

Unit of care is a term that means the focus of a plan of care. Including the family was originally a major goal of hospitalization and discharge planning. The GCM's approach is that it is not the care recipient who is the client, but the "client system" - including the family, the family caregiver, and friends - that is the client. The GCM can encourage the "unit of care" to be actively involved in the discharge plans, ensuring safe transition to home.

The care manager also alerts the family that if they feel the discharge is premature, the family and patient have a right to appeal the decision, thus ensuring that the patient goes home only when it is safe.

Hospitals are required to give every Medicare patient or family caregiver a copy of the statement about appealing dischrage decisions, "An important message about Medicare." They must make sure the family and patient, if competent, understand the process. This document spells out the patients rights to all needed hospital care and post-discharge follow-up. The hospital must also give a written notice explaining the discharge, a "Hospital-Issued Notice of Non Coverage" or HINN. The HINN includes the phone number of the local peer review organization (PRO) and other organizations that review contested cases. Care managers can help the family understand that the hospital cannot force family caregivers to take patients home or pay for continued care before the PRO makes a decision. The GCM works supportively, not adversarially, with the discharge planner and physician to mediate the situation and answer the family's or patient's questions about a nonreadiness for discharge to try to resolve the disagreement so that the patient family and discharge planner get what they need. Physicians and discharge planners are pushed by DRGs and too many patients. So the GCM's extra support can provide a way to get the patient to the point of
safe discharge.

The GCM is key, post discharge, to keeping the patient from readmission. At discharge, the families health literacy becomes critical to follow-up care. While the older family member is in the hospital, the GCM networks with local, state, and national agencies on aging to arrange condition-specific
information and training on post-acute tasks at discharge. For example, if the client has had a stroke, the GCM contacts a local or national American Heart Association for information about aftercare.

The GCM contacts the local stroke association to find out if they have training for family members to care for family at home and if they will come to the hospital pre-discharge to do the training.

The GCM can ask the physician if the hospital has a checklist of specific information about the medical conditions and needs of the elderly patient during the transition to home. This involves the family and caregivers in discharge and helps to make the transition to home smooth. The GCM can also request that the physician, discharge planner, or RN review the checklist with the patient and family to make sure the family understands the home care needs of the patient.

If the physician or the hospital has not taken steps to involve the family in the unit of care, the GCM gets the family involved through follow-up training. The GCM can ask the physician if the PT and OT can train family members in transfers and use of medical equipment pre-discharge. If this does not happen, the patient has a much greater risk of readmission because the family caregiver did not know how to render care. In addition family members could injure themselves by lifting, giving injections, or managing complex machines that they are not trained to manage.

TASK 6:
Heath Care Provider Engagement

GCMs work with the patient's primary care physicians, specialists, home care agencies, and local
caregiver organizations at admission, while the patient is in the hospital, and at discharge to ensure health care provider engagement and to help the physician support the family caregiver. The GCM can arrange caregiver training for post-acute tasks (bathing, lifting, injections, and self-care for
caregivers).

Involving a Home Care Agency

Another key health care provider is the private duty home care agency. Except for very brief coverage for post-hospitalization, Medicare does not cover home care or what it defines as long-term chronic care. So the patient and family must pay for home care unless they have long-term
care insurance. The GCM will have assessed whether the patient can afford home care as part of the initial assessment. The GCM can share the patient's financial information with the discharge planner. If the patient needs 24/7 care, with the help of the discharge planner and the hospital staff, the GCM can assess the patient's present level of care and help the patient, discharge planner, and family find the correct affordable care. All these arrangements can be the key to keeping someone at home as opposed to sending him or her back into the hospital.

The GCM and the discharge planner evaluate whether the family member who plans to render care can really do so. If the GCM compares the family members' abilities (such as ability to lift, ability or willingness to be trained in injections and in managing medical equipment such as a Hoyer lift or wheelchair) with the patient's condition at discharge, the GCM and the discharge planner can help the family member decide whether the family member can render care safely. If not, the GCM can
help build a support system that may involve informal support from other family members, close neighbors, or friends who can give injections or be trained to give injections.

TASK 7:
Shared Accountability Across Providers and Organizations - Enhancing the transition process through accountability of care of the patient by both the healthcare provider (or organization transitioning) and the one receiving the patient

It is critical for the GCM to assess the patient's home before the patient goes home. This risk assessment ensures shared accountability, a key to preventing hospital readmission. The GCM will have done this assessment as part of the original assessment. Before the older patient is released
from the hospital, the GCM revaluates the home assessment in terms of the patient's changed condition as a result of the hospitalization and shares this information with the discharge planner, family, and Medicare agency, if they are involved. This increases shared accountability by putting
everyone on the same page about a safe discharge. For instance if the patient could climb stairs before the hospitalization and now cannot, the GCM may have to investigate a ramp or first-floor bedroom. Alternative housing or placement will have to be made if modifications are not possible. The family must be involved in either case. The GCM sharing this information with all players creates
shared accountability and a safe transition to home and helps prevent readmission.

In summary, the GCM is a professional who can carry out key elements of transition in care based on the National Transitions of Care Coalition's evidence-based "Crosswalk" of seven key elements
of a transitions of care program. The GCM can and should be a key team player in the long-term care system that works together to meet CMS mandates to avoid unnecessary hospital readmission.

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