Care Transitions celebrates five years of success

Wednesday, February 15, 2017

a patient reviews medications with his care transitions coach
A Care Transitions client reviews medications with his health coach

Council on Aging’s five-year contract with the Centers for Medicare and Medicaid Services (CMS) to reduce hospital readmission rates among frail older adults has come to a close. But, a modified version of Council on Aging’s Care Transitions program will continue in four area hospitals.

Care Transitions is a health coaching program that uses person-centered interventions to help patients avoid preventable readmissions to hospitals after discharge. This revolving door syndrome is all too common, costs Medicare billions of dollars every year, and is hard on patients and their families.

A top performer among Care Transitions sites, our program is nationally-recognized for reducing readmission rates. Nine area hospitals and The Health Collaborative have been our partners in this program.

Much of the program’s success can be attributed to the team’s ability to adapt. For example, as the program progressed, Care Transitions staff identified a trend: people with behavioral health needs rely on hospitals – particularly emergency departments – to meet their medical needs. COA staff modified the standard Care Transitions model to include an emphasis on trigger points and crisis planning for people with behavioral health needs. Using this model, the readmission rate among this population was reduced to six percent.

Initially designed to serve 5,400 seniors per year and save Medicare more than $1 million annually, COA staff assessed more than 34,000 patients and enrolled nearly 24,000 in the Care Transitions program (March 2012 – September 2016). The program is estimated to have saved Medicare more than $2.5 million annually. Among participating hospitals, the readmission rate for Care Transitions participants was 14.8 percent, compared to the hospitals’ baseline readmission rate of 21.9 percent.

Care Transitions coaches will continue to work with patients at the University of Cincinnati Medical Center, Christ Hospital, Jewish Hospital and Clinton Memorial Hospital.