Care Transitions program best in country at reducing hospital readmissions

Friday, April 26, 2013

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

For the most recent reporting quarter, the Community-based Care Transitions Program (CCTP) in southwestern Ohio has been selected as the country`s top performer in helping hospitalized seniors avoid readmission to the hospital after they return home.

According to The Lewin Group, a health care consulting firm, patients who participate in our region`s care transitions program are less likely to be readmitted to the hospital during the most recent reporting quarter than patients participating in similar programs elsewhere. There are currently102 CCTP sites around the country.About two-thirds of them were active at the time of the most recent reporting quarter.

For the period Aug. 1-Oct. 31, 2012, the readmission rate among patients who completed our care transitions program was 15.2 percent. This rate is more than one-third lower than the baseline readmission rate of 25 percent.

Representatives of The Lewin Group are planning a visit to Cincinnati to meet with the team here and observe the program in action. Best practices are then shared with other CCTP sites around the country.

Operated by Council on Aging (COA), the program uses health coaches who visit patients at home and guide them on ways to manage their health. (Click here to watch a new patient story video.)  

"With our partners, we have built this program from the ground up and every day it is getting better," said Kim Clark, manager of the care transitions program for Council on Aging. "We`re constantly learning from our experiences in working with hospitals and patients and then applying what we have learned. I`m proud of our coaches and of the whole team who have worked very hard."

The Lewin Group is providing technical assistance for the U.S. Centers for Medicare and Medicaid Services. CMS is funding and evaluating selected CCTPs around the country. Through this project, CMS is seeking the best models for reducing preventable hospital readmissions among Medicare beneficiaries. The revolving door of hospital readmissions is a drain on the health care system, compromising patients` health and increasing costs.

CMS has estimated that hospital readmissions cost Medicare $15 billion a year, $12 billion of which is considered preventable. In October 2012, CMS began withholding a portion of Medicare reimbursements to hospitals with overly high readmission rates.

Council on Aging started the program in 2010 with a small pilot project at UC Health/University of Cincinnati Medical Center. In 2011, COA and the Greater Cincinnati Health Council formed the Southwest Ohio Care Transitions Collaborative with several other health care organizations and five hospitals: The Christ Hospital; Clinton Memorial Hospital; The Jewish Hospital-Mercy Health; Mercy Health-Fairfield Hospital; and UC Health-University of Cincinnati Medical Center. The collaborative was among the first seven CCTP groups in the country to be selected for funding from CMS.

The program is now operating in all five hospitals, using more than 20 care transitions specialists and coaches.

Specialists meet with eligible patients in the hospital prior to discharge. The program is voluntary and about 70 percent of patients choose to participate. The 30-day intervention includes a home visit from a health coach (typically within three days of discharge) and three follow-up phone calls. Using a model developed and proven effective by Eric Coleman, M.D., of the University of Colorado, coaches help patients organize their medications, keep a health record, connect with their physician, and recognize "red flags," a flare up of symptoms that could land them back in the hospital if ignored. Coaches also refer patients to COA in-home care services, if appropriate.

Care Transitions will be featured in an interview on WMKV`s Medicare Moment show hosted by Anne Fredrickson of Pro Seniors. The shows airs at 2 p.m. Tuesday, April 30 on WMKV, 89.3 FM and is streamed online at

More information about Care Transitions is available on our web site, where you can also find an article about the program by the Cincinnati Enquirer and an information flier for patients.

For more information:

Cincinnati Enquirer In-Depth: Care Transitions

Patient Information Flier

Video: Keeping Joann out of the hospital