Studies show that 10% of Medicare beneficiary’s early hospital readmissions were preventable. “There were 301,017 readmissions that were clinically related” (Norbert I. Goldfield, 2008) to a previous admission which was classified as be preventable or unnecessary. Statistics show that hospitals that have been effective in creating discharge plans experience lower readmission rates. Although the need for case management services has increased over the last decade, the concept is not new.  “Casework originated in the late 1800s under the ideologies of the coordination of human services, conservation of public funds, and care of poor and sick people.” (Hall, Carswell, Walsh, Huber & Jampoler, 2002) However, agencies lost momentum in the early 1900′s only to reemerge during the great depression.   “Traditional social work intervention [] focused on [] disadvantaged people who were struggling with basic survival needs”(Hall, Carswell, Walsh, Huber & Jampoler, 2002)

Currently, one in five patients discharged home from an acute care hospital cost Medicare over 17 billion dollars annually.  In 2008, “(19.6%) of the 11,855,702 Medicare beneficiaries who had been discharged from a hospital were rehospitalized within 30 days.” (Jencks, Williams, & Coleman, 2009)  There is a direct relationship between the rise in readmission rates and a patient’s socioeconomic status.  Individuals who live alone, have less than a 12th grade education, low income, chronic or mental ill or have no support system are less likely to comply with their discharge plan.  According to the 2008 US Census Report, national educational attainment of the individuals who were non-institutionalized and over 64 years old 3.9 million have 12 or fewer years of education.  (U.S. Census Bureau, 2008)

As the baby-boom generation moves into retirement the need for case management is on the rise.  Policy makers are hurrying to establish new health reform.  President Obama has pledged to have a Bill before Congress by the end of March 2010 to address the needs of aging Americans, who are disadvantaged, chronically or mentally ill.  Approximately, one in three Americans will experience some form of mental disorder at some point in their lives, and according to one estimate, one in every 6.4 adults is currently suffering from some form of mental illness.  (Boyle & Callahan, 1993) One of the areas of great concern is the impact early hospital readmissions of elderly patients have on the healthcare budget.  “The costs of caring for these patients and whose illness is episodic and curable have reached $136.1 billion per-year.” (Boyle & Callahan, 1993)  The first step to reducing this cost is to reevaluate the cause.

It is suggested that this increase is due to the number of Medicare beneficiaries receiving inadequate home healthcare. Could it be, because there are too many programs and variations to choose from?  On average each Medicare beneficiary “have at least 41 plan choices (excluding special need plans available to only qualifying subgroups) not including an extensive array of Medicare stand-alone prescription drug plans.” (Gold, 2009)

According to Medicare Provider Analysis and Review (MEDPAR) file for 2009, under the current Medicare policy, home health services consist of skilled nursing, physical therapy, occupational therapy, speech therapy, aid service, and medical social work.  (p. 201)

Conclusion:  Home health agencies have reduced the amount of services to their patients while receiving the same reimbursement.  Under the Medicare fee-for-service market basket policy, agencies only have to meet minimum requirements. They have adjusted their services to increase maximum input while providing substandard output. Moving from the current policy to an average rate for services would increase the services receive to clients, while reducing fraud. The increase of reimbursement for social services would provide needed care to individuals, whose socioeconomic status falls below the national average, thus reducing readmissions rates. Additionally, the government needs to reduce the number of special need plans (SNP) beneficiaries have to choose from; therefore, reducing entitlement confusion. These plans should mandate extra previsions for identifying and addressing the socioeconomic limitations of the more than nine million Medicare and Medicaid recipients.  Finally, case managers, nurses, and doctors need to advise all their patients of the benefits available and how to assess such services.

Method

Through meta-analysis, statistical data from secondary sources was used to gather information. Medicare recipients completed questionnaires consisting of 45 questions on a scale of 1 to 5 with 1 equaling does not apply and 5 equaling does apply. Within seven days of enrollment structured interviews were conducted at the recipient’s home.   Multidimensional variables were used to determine if there was a direct correlation between the number of Medicare Advantage plans, number of beneficiaries enrolled in a plan, and early hospital readmission rates.

There are currently 8,645,970 individuals 65 years old or older enrolled in Medicare Advantage. However, only 957,553 elderly or 10.5 percent is enrolled in a special need plan. (U.S. Census Bureau, 2008)  ORDI show  beneficiary demographics as follows: of the eligible recipients enrolled a SNP 98% were over 65 years old, 74% were male and 26% female, 70% white, 6% African American, and 14% other races.  Medicare eligibility status was 97.3% eligible due to age, 1.5% disabled, and 1.2% other.  Most of the participants lived in urban communities 57.1%, rural 42.9, and 66% lived in the community.  Individuals who lived in the rural communities rated as having a higher risk score. (p. 91)

Measurement Tools

In a research report published in 2007 by The Center for Medicare and Medicaid Services Office of the Research, Development, and Information (ORDI), committee members stated that if Congress continue to disregard the current way home healthcare for chronically ill is conduct, it will break this nation.  This information came from CMS enrollment records, claims received HCC and HMO payment file, fiscal years 2003 and 2004, starting on September 1, 2003 through August 31, 2005, 10,400 freestanding home health agencies were compared to the services offered and delivered. Of those agencies, 8,562 reported 59% of their clients being readmitted or going to the emergency room within 30 days of discharge from an acute hospital facility. Only 1 in 24 were enrolled in a special need program.

According to Jencks, Williams and Coleman (2009), of the Medicare beneficiaries who were readmitted in an acute care hospital within 30 days of discharge, 70% had an existing medical condition (p. 1) which would have been covered under Medicare Advantage if the recipient was enrolled.

Schmitz, Merrill, Schore, Shapiro, & Verdier (2007) conducted a survey of 800 organizations “to collect uniform information about their structure and operation.” (p. 38)   An eight hundred questionnaire survey was mailed 193 facilities who met ORDIs criteria. The participating companies were “ask about their population, relationships with providers, member screening and assessment, services offered, relationship with Medicaid, and pharmacy benefits. Of the surveys mailed (n=193), 11 were ineligible, 145 surveys were completed with a total response rate of 80%.  “Currently a little over half of the dual-eligible and institutional SNPs had more than 1000 members, which provided care for heart failure or other cardiovascular disease.” (p. 38)

CMS has identified the follow medical conditions as being eligible for the chronic condition classification.  Each illness must be:

• Medically complex

• Substantially disabling or life-threatening

• High risk of hospitalization or have other adverse outcome

• Needs specialized delivery system across care domains

• Has nationally recognized protocols or guidelines

The chronic conditions that meet CMS guidelines and are identified as being the primary cause of early hospital readmissions include: COPD 15.4%, Diabetes without complications 19.1%, CHF 21.7%, vascular disease 13.3%, specified heart arrhythmias 15.5%, major depression, bipolar, and paranoid disorders at 6.3%, renal failure 4.9%, angina pectoris 4.2%, cancers 3.7%, and ischemic or unspecified stroke 4.0%.

There are 12 insurance companies that over 75% of all Medicare beneficiaries.   There were 2,735 plans offered in Medicare Advantage in 2009. (The Henry J. Kaiser Family Foundation, 2009)

Implications

Failure to develop a program that would automatically cover all Medicare beneficiaries would be catastrophic for this nation.  Currently, the cost of each Medicare patient who is readmitted after the first 24 hours of discharge from an acute care hospital but within 30 days cost the government an average of $7,248 for each patient.  If you take the average cost for each readmission in 2008 and multiply them, it cost 17.4 billion dollars.   At this current rate, the country will be bankrupt by 2020.

The Prospective Payment System which is currently being used by CMS is inadequate and is over paying claims for service by some 6 billion dollars annually.   The way the current system is designed, it allows home health care to bill for and services only that pay the largest reimbursement.  Because of this some of the main causes of patients being readmitted is over looked.   Arbaje’s study conducted in 2008 measurements [on] early readmission [of patients'] postdischarge environment (PDE) factors, and socioeconomic (SES) factors to determine their needs once they are discharged from the hospital. PDE factors consisted of having a usual source of care, requiring assistance to see the usual source of care, marital status, living alone, lacking self-management skills, having an unmet functional need, having no helpers with activities of daily living, number of living children, and number of levels in the home. SES factors consisted of education, income, and Medicaid enrollment. (p. 495)  As shown in this model Arbaje illustrates emigrating factors that directly related to a person’s chance of being readmitted. (See figure 1.)

Most home health agencies overlook the importance of having social work involvement in the lives of their clients.  To increase their profits, client socioeconomic needs go un-assessed or are minimized.  They often fail to recognize “the scientific evidence concerning the effectiveness of case management services [and how] it has grown over recent years.” (Björkman, 2000)  There are a number of assessment tools currently being used by home health agencies, but there is no consistency. Social workers work with identifying client strengths. The strengths’ perspective assumes that everyone has the capacity to draw from a variety of resources, skills, abilities, motivations, desires, and talents”. (Hall, Carswell, Walsh, Huber & Jampoler, 2002) By home health agencies limiting patients’ access to a social worker, patients never obtain the confidence they need to heal and live productive lives.  Patients become more dependent on the system, thus returning to the hospital at the first sign of trouble. If this trend is not corrected the growth of hospital readmissions will continue.

Programs

There are several programs in place that may accommodate Medicare and Medicaid beneficiaries.  Let’s take a look at three.

The first program is The Providing Assistance to Caregivers in Transition (PACT) program.  This program is a case management program comprised of social workers and nurses. They develop case plans for patients who were discharged home from a facility.  It is also covered by Medicare, but not Medicaid.  However, the drawback of this program is that it is limited to only 10 visits per 60 day period and to those patients who came from a nursing home or hospital. It would be more effective is it “considers a broader mix of nursing homes, working directly with the nursing home’s admission Minimum Data Set coordinator in the patient selection, or working with Medicare or Medicaid HMO plans.” (Newcomer, 2006)

The second program which is available to patients is the special need plan offered by Medicare.  This program assists patients who have a chronic illness and is unable to handle their own affairs.  Patients can receive an unlimited amount of visits from a nurse or social worker.  However, this is an evidence base plan and is limited to those patients who will be able to develop an independent lifestyle. Unfortunately, the reimbursement under this plan is limited and few home healthcare agencies utilize it.

Then there is the intensive case management program. This plan assists “high-risk adults with chronic mental health conditions”. (Patterson, 1998) Patients are assisted with their medications and daily living.  This plan is also covered under the Medicare reimbursement policy; however, it is limited to patients with severe medical problems.  It is used by most home health agencies and is paid at a higher rate by both Medicare and Medicaid.

Recommendations

There are a number of possible solutions in handling the confusion and reduce readmission rates.  First, a reduction of the number of Medicare plans available under Medicare Advantage program should be made.  Second, there need to be nation minimum standards for all plans.  Third, all plans must carry dual enrollment programs (offering both Medicare and Medicaid). Fourth, every Medicare and Medicaid patient who is being discharged home is to be assessed by a social worker at home within 3 days of discharge.  Fifth, all assessments should be nationally universal; every state would use the same format.  Finally, patient socioeconomic information should be on a computer system and outcomes should also be posted.

A reduction of the number of Medicare plans offered under the Medicare Advantage program should be executed. There are currently some 2700 different programs available.  Each program offers a varying amount of services with just as many combinations. Additionally, some of the plans are hard to understand, while others are confusing. Some people will find that one of their illnesses is covered, while another is not.      The current plans, say a person is diagnosed with diabetes and depression; they may be under a plan that covers diabetes, but not depression or vice versa.

Each plan should have minimum standards that would cover the 12 chronically illnesses currently approved by Medicare or Medicaid as high risk.  There would be no all-inclusive plans.  Every service and treatment would be itemized with a time frame for outcomes.  Only those agencies that maintain a positive outcome base over 80% would be able to stay in the Medicare or Medicaid program.

Due to the high number of individuals who is low income all plans should be required to carry dual enrollment programs (offering both Medicare and Medicaid). Additionally, a large number of white patients live alone and because of assets do not qualify for Medicaid; therefore, the minimum standards should not be based on assets.  If the person qualified for both Medicare and Medicaid than they would have met the standards for those programs and additionally limits should not be imposed.

Conclusion

Without healthcare reform is necessary for this country to survive and reducing Medicare and Medicaid is the place which needs the biggest overhaul.  Currently costing this nation billion of dollars annually preventive health is the answer.  The only way to do this is by reducing the number insurance of plans, setting national minimum standards, increasing recipient enrollments in special need plans, and effective discharge plans these rates could be reduced. More choice does not always mean better choice.

With President Obama on the skirts of signing a new healthcare reform bill, case management needs to be an intricate part of the recovery plan.  Only through the reduction of ineffective care, government mandates and tougher penalties for   insurance companies who defraud the government will change come and patients receive the treatment they need.

References

Arbaje, A., Wolff, J., Yu, Q., Powe, N., Anderson, G., & Boult, C.. (2008). Postdischarge Environmental and Socioeconomic Factors and the Likelihood of Early Hospital Readmission Among Community-Dwelling Medicare Beneficiaries. The Gerontologist, 48(4), 495-504

Björkman, T., & L. Hansson. (2000). What do case managers do? An investigation of case manager interventions and their relationship to client outcome. Social Psychiatry and Psychiatric Epidemiology, 35(1), 43-50.  Retrieved February 14, 2010, from ProQuest Medical Library. (Document ID: 972364221). Hall, J. A., Carswell, C., Walsh, E., Huber, D. L., & Jampoler, J. S. (2002). Iowa Case Management: Innovative Social Casework. Social Work, 47(2), 132+. Retrieved March 6, 2010, from Questia database: http://www.questia.com/PM.qst?a=o&d=5000759600

Hall, J. A., Carswell, C., Walsh, E., Huber, D. L., & Jampoler, J. S. (2002). Iowa Case Management: Innovative Social Casework. Social Work, 47(2), 132+. Retrieved March 6, 2010, from Questia database: http://www.questia.com/PM.qst?a=o&d=5000759600

Jencks, S., Williams, M., & Coleman, E.. (2009). Rehospitalizations among Patients in the Medicare Fee-for-Service Program. The New England Journal of Medicine, 360(14), 1418-28.  Retrieved February 28, 2010, from ProQuest Medical Library. (Document ID: 1672517131).

Medicare Provider Analysis and Review (MEDPAR) 2009 Retrieved February 14, 2010 http://www.cms.hhs.gov/MedicareFeeforSvcPartsAB/03_MEDPAR.asp

Robert Newcomer, Taewoon Kang, & Carrie Graham. (2006). Outcomes in a Nursing Home Transition Case-Management Program Targeting New Admissions. The Gerontologist, 46(3), 385-90.  Retrieved February 14, 2010, from ProQuest Medical Library. (Document ID: 1049777191).

Patterson, David, A., & Myung-Shin Lee. (1998). Intensive case management and rehospitalization: A survival analysis. Research on Social Work Practice, 8(2), 152-171.  Retrieved February 14, 2010, from ProQuest Psychology Journals. (Document ID: 26923286).

Schaedle, Richard W., Irwin Epstein Publication title: Mental Health Services Research. New York: Jun 2000. Vol. 2, Iss.  2;  pg. 95 Source type: Periodical ISSN: 15223434 ProQuest document ID: 386427651

Schmidt-Posner, Jackie, & Jeanette M Jerrell. (1998). Qualitative analysis of three case management programs. Community Mental Health Journal, 34(4), 381-92.  Retrieved February 14, 2010, from ABI/INFORM Global. (Document ID: 32416774).

Schmitz, R., Merrill, A., Schore, J., Shapiro, R., Verdier, J. (2009). Centers for Medicare & Medicaid Services ― Evaluation of Medicare Advantage Special Needs Plans Summary Report, Contract No.: 500-00.0033(13) MPR Reference No.: 6216-711 September 30, 2008 [http://www.cms.hhs.gov/reports/downloads/Schmitz_2008.pdf]

The Henry J. Kaiser Family Foundation. (2009). Strategies for Simplifyiong the Medicare Advantage Market. Washington, DC: Mathematica Policy Research, Inc. .

U.S. Census Bureau. (2008, Januay 1). Educational Attainment of the Population 18 Years and Over, by Age, Sex, Race, and Hispanic Origin: 2008. Washington, DC, Unite States.

Hall, J. A., Carswell, C., Walsh, E., Huber, D. L., & Jampoler, J. S. (2002). Iowa Case Management: Innovative Social Casework. Social Work, 47(2), 132+. Retrieved March 6, 2010, from Questia database: http://www.questia.com/PM.qst?a=o&d=5000759600

Jencks, S., Williams, M., & Coleman, E.. (2009). Rehospitalizations among Patients in the Medicare Fee-for-Service Program. The New England Journal of Medicine, 360(14), 1418-28.  Retrieved February 28, 2010, from ProQuest Medical Library. (Document ID: 1672517131).

Robert Newcomer, Taewoon Kang, & Carrie Graham. (2006). Outcomes in a Nursing Home Transition Case-Management Program Targeting New Admissions. The Gerontologist, 46(3), 385-90.  Retrieved February 14, 2010, from ProQuest Medical Library. (Document ID: 1049777191).

Patterson, David, A., & Myung-Shin Lee. (1998). Intensive case management and rehospitalization: A survival analysis. Research on Social Work Practice, 8(2), 152-171.  Retrieved February 14, 2010, from ProQuest Psychology Journals. (Document ID: 26923286).

Schaedle, Richard W., Irwin Epstein Publication title: Mental Health Services Research. New York: Jun 2000. Vol. 2, Iss.  2;  pg. 95 Source type: Periodical ISSN: 15223434 ProQuest document ID: 386427651

Schmidt-Posner, Jackie, & Jeanette M Jerrell. (1998). Qualitative analysis of three case management programs. Community Mental Health Journal, 34(4), 381-92.  Retrieved February 14, 2010, from ABI/INFORM Global. (Document ID: 32416774).

Schmitz, R., Merrill, A., Schore, J., Shapiro, R., Verdier, J. (2009). Centers for Medicare & Medicaid Services ― Evaluation of Medicare Advantage Special Needs Plans Summary Report, Contract No.: 500-00.0033(13) MPR Reference No.: 6216-711 September 30, 2008 [http://www.cms.hhs.gov/reports/downloads/Schmitz_2008.pdf]

The Henry J. Kaiser Family Foundation. (2009). Strategies for Simplifyiong the Medicare Advantage Market. Washington, DC: Mathematica Policy Research, Inc. .

U.S. Census Bureau. (2008, Januay 1). Educational Attainment of the Population 18 Years and Over, by Age, Sex, Race, and Hispanic Origin: 2008. Washington, DC, Unite States. http://www.census.gov/aboutus/budget.html