Pilot Targeting Senior Care Transitions Drastically Reduced Readmission Rate

A pilot program focusing on transitions between levels of care—including hospitals and skilled nursing facilities—has yielded hugely successful outcomes in reducing rehospitalizations, with the potential of spreading to more post-acute senior care settings. 

Healthcare reform initiatives have emphasized reducing preventable hospital readmissions, and in October, the Centers for Medicare & Medicaid Services (CMS) began implementing reimbursement cuts to hospitals with higher-than-expected readmission rates.

While preventing rehospitalizations might not prove to be an easy fix, a session during the Aging in America Conference in Chicago last week suggested that collaboration between various health providers can be one way to significantly reduce them. 


Through funding from both CMS and the Administration on Aging (AoA), the Aging & Independence Services (AIS) and Aging and Disability Resource Connection (ADRC) have been able to achieve significant reductions in hospital readmissions through the Care Transitions Intervention (CTI) Program.

“I truly believe that all communities that are a part of this program have the opportunity to learn from one another and make system-wide changes to reduce readmissions in this country,” said AIS Aging Program Administrator Brenda Schmitthenner in a conference session about the CTI program.

During a CTI pilot in 2009, a partnership between Sharp Memorial Hospital in San Diego and AIS/ADRC saw only seven readmissions from a total sample of 88 patients. 


Developed by Eric Coleman, MacArthur Fellow and Professor at the University of Colorado School of Medicine, the CTI model incorporates what are called the “Four Pillars” of criteria to ease a patient’s transition period from the hospital to a skilled nursing facility or the home.

These Four Pillars include the establishing and maintaining of patients’ personal health records, medication lists, specialist follow-ups and recognition of “Red Flags,” or symptoms of chronic illness.

Sharp Memorial Hospital ended up adopting the CTI Program following the success of the pilot, and now it has expanded to the University of California San Diego Medical Center and Scripps Mercy Hospital.

The CTI model even led to the birth of another initiative to reduce hospital readmissions called the San Diego Care Transitions Partnership (SDCTP) Design.

To design SDCTP, AIS collaborated with a variety of San Diego health care providers as well as the UCSD Health System with the central mission of improving quality of care for patients during transition periods, while also reducing readmissions for high-risk beneficiaries.

“SDCTP is committed to reducing readmissions by 20% in two years,” says Schmitthenner. “Failure is not an option.”

The program also looks to include what it calls “care enhancement,” which entails providing transportation, durable medical equipment not covered by Medicare, and homemaker assistance, including medication pickup and shopping errands.

Additionally, some key elements of care enhancement also include coordination with the patient’s care team, hospital visit-discharge assessment, and home visits 24-72 hours of discharge.

The SDCTP will serve approximately 21,000 fee-for-service Medicare patients with various interventions that include: using assessment tools to conduct risk screening, using a high-risk health care coach to coordinate care and handoff to other providers upon discharge, using a pharmacist for medication education, as well as transitioning patients into palliative care and hospice.

Currently, Schmitthenner says the SDCTP design team is customizing an IT solution for invoicing, data collection, monitoring and reporting to compile a database that shows what hospitals provided which types of interventions.

The transition between care settings can sometimes induce harmful side effects on a patient’s physical well-being, according to the American Medical Directors Association, making programs that focus on coordinated care during these transitional periods necessary to ensure patients leaving institutional settings remain healthy during the recovery process.

Written by Jason Oliva