Care Transitions and the economics of hospital readmissions

Care Transitions Client
Care Transitions client, Joann, reviews her medications with her Council on Aging coach, Alisa

Council on Aging of Southwestern Ohio, in partnership with the Greater Cincinnati Health Council and several area hospitals and health care organizations, was one of the nation`s first recipients of a major federal contract designed to reduce hospital admissions among seniors.

The Center for Medicare and Medicaid Services (CMS) has contracted with Council on Aging to provide coaching to hospitalized seniors on how to get home, stay healthy, and avoid return visits to the hospital. Council on Aging works with the Southwest Ohio Community Care Transitions Collaborative to provide these services.

Council on Aging estimates that the program will serve nearly 5,400 seniors per year and save Medicare an annual net savings over $1 million dollars annually. Savings are achieved through reductions in hospital readmissions.

The Need

Readmissions Info GraphicThrough this award, CMS has recognized the important role Council on Aging plays as the Area Agency on Aging in helping older adults transition smoothly among different care settings. In seeking remedies for the nation`s fragmented health care system, CMS required that funding applicants be or include community-based organizations, such as Area Agencies on Aging, that contribute to better healthcare outcomes for older adults.

According to the Center for Medicare and Medicaid Services, Medicare beneficiaries who are discharged from hospitals are increasingly being readmitted for avoidable conditions within 30 to 90 days. Much of this is due to a fragmented health care system which does not adequately support patients during the vulnerable time when they are transitioning from the hospital to other settings, such as nursing homes, rehabilitation facilities and their own homes. The cost to Medicare for hospital readmissions is estimated at $15 billion a year, $12 billion of which is for cases considered preventable.

Beginning in October, 2012, Medicare began withholding a portion of payments to hospitals with high readmission rates for patients with certain conditions such as heart failure and pneumonia. The 30-day hospital readmission rate in southwestern Ohio ranges up to 29 percent for these conditions in some hospitals.


  • Of the patients in southwestern Ohio admitted to a hospital with pneumonia, heart attack or heart failure in 2008, 24% were discharged to a skilled nursing facility, about eight percent more than the national average. Of all post-acute care settings, skilled nursing facilities are the most likely to refer patients to hospitals for readmission.
  • Adults are often placed in nursing homes because they do not have essential services which can be provided at home for about one-third the cost.
  • 90 percent of patients who are readmitted to a hospital experienced a breakdown in post-discharge care. 
  • The Healthcare Intelligence Network has recently created a set of info graphics illustrating the high cost of avoidable hospital readmissions and offering ideas to keep readmission rates down.

[return to top]

The Solution

Based on the proven Care Transitions Intervention developed by Dr. Eric Coleman of the University of Colorado, southwestern Ohio`s Care Transitions program uses coaching, health information technology, help with medications, and chronic disease self- management to help hospitalized seniors get home and stay home.

Electronic health information and exchange: Immediate identification of patients likely to benefit

Person-centered care; coordination of care as patients transition from one setting to the next; health coaching:

  • While in the hospital, participants meet with Council on Aging Care Transitions Specialists (also known as coaches) and receive Personal Health Records, for setting health goals, listing questions for doctors, and recording their medical information and instructions.
  • Within three days after hospital discharge, Care Transitions Specialists visit the patient at home or in a nursing facility. They also complete three phone calls to the patient at regular intervals post-discharge. They ensure patients follow up with their personal physicians and medical specialists (who often aren`t aware their patients are in the hospital), and reconcile patients` existing and new medications. (Medication mix ups are a major reason for avoidable re-hospitalizations.)

Care in the setting of patient choice; avoiding unnecessary institutionalization: Partners in the Southwest Ohio Communication Care Transitions Collaborative connect patients to community resources. Eligible patients are referred to Council on Aging`s in-home and community-based care programs, where care management saves public funds by helping clients remain independent in the lowest cost settings (home and assisted living).

Evaluating outcomes; managing quality: Partners in the collaborative are responsible for: using health information technology to support Care Transitions; monitoring daily operations to ensure compliance with the Care Transitions model; analyzing patient outcomes; and designing innovations and quality improvements.

[return to top]

The Results

According to a report of the Coleman Care Transitions InterventionSM, patients who participated in the program were significantly less likely to be readmitted to the hospital, and the benefits were sustained for five months after the end of the one-month intervention. Anticipated cost savings over 12 months is $295,594 for a typical Transitions CoachTM panel of 350 chronically ill adults with an initial hospitalization. Patients who received this program were also more likely to achieve self-identified personal goals around symptom management and functional recovery.

Preliminary results of Council on Aging`s pilot program at the University of Cincinnati Medical Center, showed participants had a lower than average hospital readmission rate and most patients were discharged to their homes or other community setting (such as assisted living) rather than to skilled nursing facility. Of those who went to a nursing facility for rehabilitation, most had a short stay and then returned home or to community setting.

Since the contract was awarded in November 2011, CMS has been measuring the southwest Ohio collaborative on its ability to reduce hospital readmissions, improve patient satisfaction, and generate savings to Medicare.

In the first nine months of 2014, 3,126 patients completed the 30-day intervention. Compared with 2013, we achieved a 62 percent increase in the number of participants and a 10 percent increase in the rate of completion. Of those who started Care Transitions, 11.2 percent were readmitted to one of the participating hospitals within 30 days of discharge, This rate is significantly lower than the national readmission rate for Medicare patients, which is approximately 17 percent. It’s also 1 percent lower than in 2013.

For the period July 2014 through June 2015, just 11 percent of our Care Transitions patients are readmitted to the hospital within 30-days of their initial discharge, compared with the national average of 21.3 percent.* In 2015, more than 7,500 patients were accepted into COA's Care Transitions program and received an visit from a COA health coach.

During a recent reporting quarter, the Community-based Care Transitions Program (CCTP) in southwestern Ohio was recognized as the country`s top performer in helping hospitalized seniors avoid readmission to the hospital after they return home. There are 102 CCTP sites around the country.

*Program is a top performer in the Community Care Transitions Project of the U.S. Centers for Medicare and Medicaid Services. Readmission rate is based on July 2014 - June 2015 data and includes our nine participating hospitals only.

[return to top]

 |  CMS Login
175 Tri County Parkway | Cincinnati, OH 45246 | (513) 721-1025