Kern County has achieved the highest percentage reduction in hospital readmissions in California – a massive 37% reduction in 30-day readmissions – among patients who have received social service support to help them transition from hospital to home. The data comes from a study carried out by CMS – The Centers for Medicare & Medicaid Services – into the Community Care Transitions Program (CCTP) operated in Kern County by Partners in Care Foundation, a not-for-profit agency that works with adults with complex health and social service needs.
Nationally, nearly one in five Medicare patients discharged from a hospital—approximately 2.6 million seniors—are readmitted within 30 days, causing considerable distress for patients and their families, and at an annual costs of over $26 billion.
The Community Care Transitions Program provides specially trained health coaches to work with high-risk patients recently discharged from the hospital, helping them to make a smooth transition from the hospital back into the home setting. A health coach visits with a patient at home to assess the person’s needs, connect them with any essential services like meal delivery and transportation, help them to manage their medications and medical appointments, and learn how to identify the red flags of a worsening condition.
Desiree Ingalls, Director of Health Services for Partners in Care in Kern County said, “We ran the program in five Kern County hospitals – Bakersfield Heart, Dignity Health Memorial, the two Dignity Health Mercy hospitals, and San Joaquin Community Hospital. Given its success, we are developing strategies to ensure that this kind of healthcare innovation, which has improved the lives of so many people and significantly reduced healthcare costs, will continue as a component of our care system.”
About Partners in Care Foundation: Partners collaborates with physician networks, health plans, community-based organizations, and federal and state agencies to deliver programs and services that protect and support adults with complex health and social service needs, including frail elders, people with disabilities, caregivers and families. Our programs have been demonstrated to significantly reduce costly hospital readmissions, emergency room visits, and nursing home placements, resulting in improved health outcomes at lower cost through better coordinated care.