Care Transition Choices

Avoid re-hospitalization of high-risk patients and cut costs with Care Transition Choices

According to data from the Centers for Medicare and Medicaid Services (CMS), nearly one in five Medicare patients discharged from a hospital—approximately 2.6 million seniors—are readmitted within 30 days, at a cost of over $26 billion every year.* To help stem such high rates of readmittance, improve patient experience, and establish cost savings to the Medicare program, the Community Care Transition Program (CCTP), a test program created under the Affordable Care Act, was established by CMS in February 2012 to test models of transitionary care for high-risk Medicare patients.

Though CMS funding for CCTP has now ceased, the success of the pilot program has seen the care transition model being adopted by private health plans and physician groups, keen to reduce the revolving door of hospital discharge and readmittance.

We are always excited to form new collaborations. If you think Care Transitions might be right for your organization, please reach out to Ester Sefilyan, Senior Director of Health Services at or 818 837 3775 x 106.

* Retrieved May 18, 2015

How does Care Transition Choices work?

Partners staff of care transition coaches work with high-risk patients to build health self-management skills, review medication use, and identify the red flags of a worsening condition. When possible, a care transition coach first visits the patient in hospital to explain the benefits of the care transition, gain patient agreement to participate and to coordinate one of two, 30-day evidence-based interventions:

1. Coleman Care Transitions Intervention (CTI) is a coaching intervention that provides an in-home visit within 24-72 hours of discharge, and a further 3-4 phone contacts within 30 days. The aim is to strengthen patient skills in health self-management, to ensure PCP and specialist appointments are kept, and to monitor for any signs of worsening symptoms. Coaches also conduct an assessment to establish potential fall hazards or other safety issues, undertake a full medication review via Partners HomeMeds℠ data collection, and link patients and their caregivers to resources such as home-delivered meals and wheel-chair equipped transportation. Patients are also provided with a Personal Health Record to track provider information, medical appointments, health conditions, medications and personal health goals.

2. Bridge Care Coordination is a telephone-only intervention for patients who live out-of-area, who refuse in-home visits, or are too cognitively impaired to benefit from health self-management coaching. Coaches make an initial phone call to patients within 48 hours of discharge to assess needs. During the subsequent 30-day intervention period, coaches coordinate with patient support resources, and then call at the end of the intervention period to assess progress.

Who are our partners?

Partners longstanding work in the provision of evidence-based, in-home support services and strong relationships with regional hospitals and physician networks resulted in the Centers for Medicare and Medicaid awarding Partners’ one of only 72 CCTP grants nationally.

That grant funding paved the way for collaborations with hospitals and medical providers in three regions of Los Angeles County: Glendale (Dignity Health Glendale Memorial Hospital, Glendale Adventist Medical Center, USC Verdugo Hills Hospital), Kern County (Bakersfield Memorial Hospital, Mercy Hospital, Kern Medical Center, San Joaquin Community Hospital, Bakersfield Heart Hospital) and Westside (Ronald Reagan UCLA Medical Center, UCLA Medical Center, Santa Monica, Providence Saint John’s Health Center.)

What were the results of care transition interventions via CCTP?

In February 2015, the Center for Medicare and Medicaid Services renewed Partners’ CCTP grant funding for a third year, based on impressive outcomes for patients participating in care transitions.

The graph compares the pre and post pilot readmission rates for the collaboratives during the three years of the pilot, comparing the hospital baseline readmission rate prior to CCTP intervention with the readmission rate in the CCTP intervention group.

More than 25,000 people have benefited across the three collaborative sites, with an estimated $16.5 million saved in unnecessary re-admission costs.

Kern County achieved the highest percentage reduction in hospital readmissions in California – a massive 41.5% reduction in 30-day readmissions – among patients who have received social service support to help them transition from hospital to home.

Commenting on the program Anwar Zoueihid, VP of Health Services at Partners, who has led the program since it began in 2012, said, “Partners is one of the few community-based organizations in the country to deliver the CCTP program at more than one community (group of contiguous hospitals) site. The data speaks for itself, but behind that data are thousands of people who otherwise would have ended up back in the hospital, a skilled nursing facility or a nursing home. The program doesn’t only save money – it reduces suffering for so many.”

Based on the success of the program, Partners has organized the Partners at Home Network to provide broad regional coverage. This has also been of great interest to private health plans and hospital systems, resulting in private contracts with seven healthcare organizations, and discussions with several more.

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