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Program Summary

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The Program

During a 4-week program, patients with complex care needs receive specific tools, are supported by a “Transition Coach,” and learn self-management skills to ensure their needs are met during the transition from hospital to home.

Value Proposition

• Reducing rehospitalization helps contain costs for complex patients and improves hospital bed capacity for patients admitted with more favorable DRGs.
• The program is self-sustaining.
• The program is consistent with both Medicare Advantage and Medicare fee-for-service financial incentives.
• The program promotes better performance on new JCAHO initiatives aimed at post-hospital care.
• Click here to read the Care Transitions Intervention business plan.

Key Findings

Patients who received this program were:

• Significantly less likely to be readmitted.
• More likely to achieve self-identified personal goals around symptom management and functional recovery.

Findings were sustained for as long as six months after the program ended.

How Can I Learn More?

• The Care Transitions Program^SM team has helped leading health care delivery systems adapt the program to their unique environments.
• Support is available for program adoption. A training manual and DVD are available on this site to prospective health systems at no charge.

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