Study: NYC Care Mgt Pilot Drops Readmissions by 37%

NYAPRS Note: Here are some impressive results in reducing avoidable readmissions by a NYC pilot that matched a nurse, care manager, health navigators and a pharmacist with Medicaid beneficiaries at the point of hospital discharge. Peers are increasingly demonstrating their great effectiveness in serving as such navigators, leading ACHMA President Ron Manderscheid to write in Behavioral Healthcare that “we (now) have a very large cadre of peers who want to become peer supporters and who are fully capable to do so. They can provide navigation for insurance, access, and care, and they can coordinate complex care as well, especially in the newly emerging health homes. Further, we can and should encourage the development of more consumer-operated service programs (COSPs) that can be attached to new accountable care organizations.”


Readmissions Pilot

Crain’s Health Pulse  August 22, 2012


Health experts have been aggressively tackling the problem of reducing hospital readmissions before Oct. 1, a date that triggers cuts in federal reimbursement.

A pilot program by EmblemHealth has had promising results, according to an article in this week's American Journal of Managed Care.

Patients who got additional services and medical care after leaving the hospital had fewer readmissions, and the savings outweighed the pilot's costs.

In 2010, EmblemHealth dispatched a nurse, a social worker, a pharmacist and two health navigators to a large group practice to deliver transitional care and services to the insurer's members following hospitalization.

They made sure people kept follow-up appointments and took their medications as prescribed. The pilot consisted of 244 members in a baseline group and 298 in an intervention group.

Some 17.6% of people in the first group were readmitted, compared with 12.1% in the second, a 31% drop in the readmission rate. The number of readmissions per member fell by almost 37%, while total hospital days plummeted by 43%. Click here for the article


Impact of Point-of-Care Case Management on Readmissions and Costs (Excerpt)

Andrew Kolbasovsky, PsyD, MBA; Joseph Zeitlin, MD; and William Gillespie, MD

(Am J Manag Care. 2012;18(8):e300-e306)


A POC (point of care) team consisting of a nurse case manager, social worker case manager, pharmacist, and 2 health navigators was integrated into a large urban medical group to work with hospitalized health plan members at 4 medical offices. These offices provide services to approximately 23,000 members under a capitated financial arrangement. These health plan members account for approximately 75% of the medical group’s patients; the remaining 25% are members of other health plans. Each of the offices provides both primary care and specialty services.

On a daily basis, hospitalized members were referred to a member of the POC team who, prior to discharge, attempted to contact the member via telephone for enrollment in the program. During the initial contact, the POC team member introduced the program and confirmed all contact information.


In the weeks following initial contact, the team member:

  • discussed the importance of aftercare;
  • ensured that a timely aftercare appointment was made;
  • provided appointment reminders and rescheduled any missed aftercare appointments;
  • performed a needs assessment and linked the member to health plan, medical group, and community resources;
  • coached the member on communicating with the PCP;
  • reviewed how to access care resources such as after-hours and express care;
  • identified red flags for readmission;
  • developed a plan of action;
  • identified any barriers to treatment or medication adherence; and
  • worked with the member to overcome these barriers.

In addition, the POC team arranged for the pharmacist to conduct medication reconciliation.


The pharmacist reviewed medication lists and had telephone or in-person meetings with members. In addition to their own caseload, each team member was also available to consult on cases whenever their specific specialty was needed. Health plan members were able to speak with the POC team via telephone or have face-to-face meetings in the medical office. The team had access to members’ clinical information in the electronic medical records used by the medical group...