Care Transitions 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 Care Transitions is right for your organization, please reach out to Ester Sefilyan, VP, Network 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. 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.