Care Transition to Reduce 30-Day Readmissions

Project 2.b.iv Care transitions intervention model to reduce 30-day hospital readmissions for chronic health conditions.

Alliance staff contact: Nora Baratto | 518.701.2198Project Resources-01

Objective: Provide a 30-day supported transition period after a hospitalization to ensure discharge directions are understood and implemented by the patients at high risk of readmission, particularly those with cardiac, renal, diabetes, respiratory and/or behavioral health disorders.

Project Description: A significant cause of avoidable readmissions is non-compliance with discharge regiments. Non-compliance is a result of many factors including health literacy, language issues, and lack of engagement with the community health care system. Many of these can be addressed by a transition case manager or other qualified team member working one-on-one with the patient to identify the relevant factors and find solutions. The following are components to meet the three main objectives of this project: 1) pre-discharge patient education; 2) care record transition to receiving practitioner; and 3) community-based support for the patient for a 30-day transition period post hospitalization.

Definition of Engaged Patients: The number of participating patients with a care transition plan developed prior to discharge.

Project Requirements:

  • Develop standardized protocols for a Care Transitions Intervention Model with all participating hospitals, partnering with a home care service or other appropriate community agency.
  • Engage with the Medicaid Managed Care Organizations and Health Homes to develop transition of care protocols that will ensure appropriate post-discharge protocols are followed.
  • Ensure required social services participate in the project.
  • Transition of care protocols will include early notification of planned discharges and the ability of the transition care manager to visit the patient in the hospital to develop the transition of care services.
  • Protocols will include care record transitions with timely updates provided to the members’ providers, particularly primary care provider.
  • Ensure that a 30-day transition of care period is established.
  • Use electronic health records (EHRs) and other technical platforms to track all patients engaged in the project.