A recent study revealed that case management programs helped improve hospital quality and led to reductions in hospital readmission rates.1

Readmission rates are a problem throughout New York, says Michele L. Summers, PhD, RN-BC, FNP-C, clinical assistant professor at Decker College of Nursing and Health Sciences, Binghamton University in Binghamton, NY.

Summers studied the programs that affect readmission rates by reviewing New York state hospital readmissions through data collected from state and federal sources. Then, she contacted hospitals to find out what types of case management and other programs they were using.

“I looked at and then eliminated data from hospitals in more metropolitan areas, including nine areas of New York City, because I wanted a better comparison of hospitals in micropolitan or rural areas,” Summers says.

Almost all the hospitals studied employed interdisciplinary case management. The study revealed hospitals that collaborated with home health agencies, used telehealth, or made house calls experienced lower readmission rates related to pneumonia.1

Case management services and referrals to home health agencies were among the main factors that affected readmission rates, Summers says.

“We asked whether they provided follow-up with recently discharged patients with a phone call from the hospital,” she says. “We wanted to know whether the hospital used some type of program where the nurse practitioner or physician would do a house call for some of their patients.”

Summers also investigated the details of the interdisciplinary case management or discharge planning team to see what level of nursing was involved. Some teams consisted of social workers, and others had a mix of nurses and social workers, she adds.

The main result was that hospitals with advanced practice nurses on their case management teams seemed to experience better outcomes, Summers says. The outcomes included readmission rates and Medicare penalties. Case management practices that led to good results included telehealth outreach, house calls, and hospital readmission reduction programs.

“If they had more than one of these programs, it was better,” Summers says. “Also, hospitals that collaborated with certified home health agencies showed a lower overall readmission rate when compared with hospitals that didn’t collaborate.”

House calls were particularly successful in some areas with reducing penalties for organizations, she notes. “The house call should be expanded more as a model, where there may be designated people who could follow up and go to people’s homes,” Summers says. “Some hospital organizations are investing in a program like that.”

These investments should be forward-thinking, putting money up front to save money in readmissions and Medicare penalties, Summers explains. “These programs give a good return on investment,” she says.

But when hospitals fund their own preventive programs, such as house calls, it can be the first program cut when the hospital is under financial restraints, Summers says.

“I think we’re moving in the right direction with reform, but more needs to be done,” she adds.


  1. Summers ML, Atav S. Reducing hospital readmissions in Upstate New York: Teasing out the effective programs. Prof Case Manag 2020;25:26-36.