Community-Based Care Transitions Program Saves $16.5 Million in Readmission Costs

Last Updated May 23, 2022

Following a three-year pilot, data from the Centers for Medicare and Medicaid Services (CMS) clearly shows that the Community-Based Care Transitions Program (CCTP) has significantly reduced the number of people being readmitted to hospital within 30 days. According to national CMS data, nearly one in five Medicare patients discharged from a hospital—approximately 2.6 million seniors annually—are readmitted within a month, at a cost of over $26 billion.

Partners has been running the CCTP program in eleven hospitals across Kern County, Glendale and West Los Angeles, providing trained health coaches to work with high-risk Medicare patients. Coaches help patients to develop health self-management skills, ensure medical appointments are kept, monitor for any signs of worsening symptoms and, for patients who request in in-home visit, also undertake a full medication review via Partners HomeMeds℠ data collection. Depending on the intervention type, coaches may also conduct an assessment to identify potential fall hazards or other safety issues, and link patients and their caregivers to resources such as home-delivered meals and wheelchair equipped transportation. More than 25,000 people have benefitted, with an estimated $16.5 million saved in avoided re-admission costs.

CCTP provides two forms of intervention, based on patient preference: the Coleman model, which provides an in-home visit within 24-72 hours of leaving the hospital, and a further 3-4 phone contacts within 30 days; or the Bridge Care Coordination model, 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 coaching.

Commenting on the success of 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.

For more information on CCTP, HomeMeds and the Partners at Home Network,

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