Transitioning to Reduce
Readmissions and
Lower Medicare Costs

In a randomized clinical trial and then in a follow-up study, the Care Transitions Intervention (CTI) has proven to be a cost-effective way to reduce unnecessary hospital readmissions by empowering patients and their families.

CTI was developed by Eric A. Coleman, MD, MPH, professor of medicine at the University
of Colorado Health Sciences Center (Leading Change). It equips patients and families with the self- management skills needed to make the transition from hospital to home or other settings safer, significantly reducing return trips to the hospital in the process. Over the course of four weeks, a specially trained Transitions Coach meets the patient and family in the hospital, conducts one home visit within two days of discharge, and then provides three follow-up phone calls.

Fact: Anticipated net cost savings over 12 months for a typical Transitions Coach consulting with 350 chronically ill adults following an initial hospitalization is conservatively estimated at $300,000.

The Care Transitions Intervention model focuses on patients at high risk for complications or re-hospitalization. During the four-week Care Transitions program, patients with complex care needs and family caregivers work with a trained nurse—a Transition Coach—to learn self-management skills that will facilitate their transition from hospital to home.

During the home visit, the Transition Coach reviews the older adult’s medication. Patients track prescriptions and instructions from numerous doctors and health care providers with the Personal Health Record.

“A coach does not take care of anything for the patient,” says Jane Brock, MD, MSPH, chief medical officer at the Colorado Foundation for Medical Care, which has run federally funded studies of CTI in Colorado and then among Quality Improvement Organizations (QIO) in 14 states. “The coach coaches the patient to take care of things for themselves.”

CTI’s ties to the Hartford Foundation run deep. But it has achieved widespread dissemination with more than 900 sites in more than 40 states through an ever-widening series of partnerships.

During the last 15 years, Dr. Coleman and CTI have received support from a variety of private foundations. Early in his career, he was a Robert Wood Johnson clinical scholar, as well as a Hartford Centers of Excellence scholar and a recipient of the Paul B. Beeson Career Development Award in Aging Research (The Best of Both Worlds: Forging a Model Public-Private Partnership). The Robert Wood Johnson Foundation funded an initial non-randomized trial of Dr. Coleman’s Care Transitions Intervention, and the Hartford Foundation supported a two-site randomized trial to produce more conclusive evidence.

In the beginning, Dr. Coleman says, “No federal funder was willing to take that kind of risk with us. I cringe when I hear the words ‘paradigm shift,’ but that’s really what it was.”

Private supporters, however, recognized the program’s potential and provided critically needed “seed money” to build the program’s capacity.

Fact: A federally funded study in Colorado found that the Care Transitions Intervention reduced 60-day hospital readmissions rates by 50 percent.

“Care Transitions could not have been disseminated as widely and effectively as it has without the partners who had the foresight to invest in this important intervention,” says Amy J. Berman, RN, senior program officer for the Hartford Foundation.

In addition to support from the Robert Wood Johnson and Hartford Foundations, CTI has received additional funding through the years from the California HealthCare Foundation, the Gordon and Betty Moore Foundation, Health Foundation for Western and Central New York, the Grotta Fund, and others.

The federal government has taken notice as well. The program served as a model for—and has received a major boost from—Section 3026 of the 2010 Affordable Care Act, which created the Community-based Care Transitions Program (CCTP). With an initial $500 million budget, CCTP is seeking to improve transitions from the inpatient hospital setting to other care settings, enhance quality of care, reduce readmissions for high-risk beneficiaries, and demonstrate measurable savings to the Medicare program.

Evidence-based care transitions, such as Eric Coleman’s, are the kinds of innovative approaches we need to transform our health care system so it delivers high-quality care at a lower cost to older adults.” Kathy J. Greenlee, JD
Assistant Secretary for Aging
Administration for Community Living

Through the advocacy of Dr. Coleman and U.S. Senator Michael Bennet, CCTP also has an innovative partnership component of its own. It requires the collaboration of a community-based organization (e.g., an area agency on aging or senior center) and a hospital, rather than enabling a hospital or more conventional home health agency to run a program on its own. This enables the long-term relationships and unique insights of community organizations to inform the implementation of these new efforts to improve transitions.

Of the first 102 sites participating in the CCTP’s work to speed the uptake of several evidence-based programs related to care transitions, 77—or 75 percent—have adopted the CTI.

Momentum continues to build on many fronts. If the program’s development to date is any indication, the Care Transitions Intervention will likely engage many more private and public partners to ensure this dynamic work is taken up in communities across the country. These funders, along with the hundreds of sites around the country, are also a dynamic source of continued improvements for the intervention and its diffusion. “We continue to learn from each of our partners,” says Dr. Coleman.

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