Collaboration of Care Journey Offering Care Transitions Intervention Training

Staff Report From South Carolina CEO

Thursday, June 28th, 2018

Collaboration of Care Journey continues to support South Carolina hospitals in their efforts to reduce readmission rates by offering the Care Transitions Intervention training created by MacArthur Fellowship winner Dr. Eric A. Coleman.

During this four-week intervention, patients with complex care needs and family caregivers receive specific tools and work with a Transitions Coach to learn self-management skills that will ensure their needs are met during the transition from hospital to home. This low-cost, low-intensity evidence-based intervention is comprised of a home visit and three phone calls.

When organizations are trained by the Care Transitions Program and follow model fidelity, they can expect reductions in readmission rate of 20-50% depending on current readmission rate. Reducing readmissions can also improve your CMS Star rating.

Anticipated net cost savings for a typical Transitions Coach panel of 350 chronically ill adults with an initial hospitalization over 12 months is conservatively estimated at $365,000. Patients in this program were also more likely to achieve self-identified personal goals around symptom management and functional recovery.

A recent program evaluation found Anthem Ohio CTI participants had approximately 18% fewer 30-day readmissions in comparison to other members with similar acuity, diagnoses and demographics. Member engagement rates for this population was more than 50% with significant improvement in the number of post-discharge appointments. In addition, the evaluation showed CTI participants had a total health care savings of $247.60 PMPM.