Care Transitions, So Hot Right Now

You may have heard the buzz about care transitions as an aging professional, or health care professional, or even if you are simply keeping up on current events.  Transitions in care are a form of care coordination during a transitional event.  Care transitions are broadly defined.  Here are a few examples: transitioning within a hospital from the emergency room to an in-patient floor; transitioning from a nursing home back home; transitioning from private payer health insurance to Medicare.  Right now the focus is on the transition from the hospital—and there’s good reason for this.  Here’s a few key numbers to explain why:


According to a study published in the New England Journal of Medicine in April 2009, 19.6% of Medicare beneficiaries discharged from a hospital stay were readmitted to a hospital within 30 days.  That means almost 1 out of every 5 Medicare beneficiaries to leave the hospital returns in 30 days or less!  If you open the window of time after discharge to 90 days, this number jumps to 34%–this is more than 1 out of 3 Medicare beneficiaries.  In Illinois, the study showed our 30-day readmissions to be slightly higher than the national average at 21.7%.

$17.4 Billion

According to the same article referenced above, the cost of the readmissions for Medicare beneficiaries totaled $17.4 Billion for one year!  This is almost 17% of the $102.6 billion that Medicare reimbursed hospitals for the year of the study.  With health care costs in the United States continuing to increase, care transitions are understandably an identified area for health care systems improvement.

$500 Million

In accordance with section 3026 of the Affordable Care Act, CMS made $500 Million available for the new Community Care Transitions Program (CCTP).  CCTP is a unique funding opportunity for community-based organizations (CBOs) to lower readmissions to the hospital.   CBOs are able to apply for reimbursement of care transition service provision through a Medicare fee-for-service mechanism.  CCTP requires CBO partnership along the continuum of care including: hospitals, skilled nursing facilities, home health agencies and more.


The Illinois Hospital Association is partnered with Blue Cross Blue Shield of Illinois to address high hospital readmission rates through the “PREP” Program.  PREP stands for Preventing Readmissions through Effective Partnerships, and 201 hospitals in Illinois have pledged to lower hospital readmissions in the state by 2014.  One of the five initiatives of the PREP Program is improving transitions of care.


Section 3025 of the Affordable Care Act introduces penalties to hospitals for preventable readmissions.  Starting in 2013, Section 3025 allows CMS to withhold up to 1% of Medicare payment reimbursement to hospitals.  By 2015, up to 3% of Medicare reimbursement to hospitals may be withheld due to preventable readmissions.  This means that hospitals that do not improve their readmission rates will receive an overall reduced Medicare reimbursement from CMS.  For medium to large hospitals, a 1% reduction in reimbursement is estimated to cost from $500,000 to $1,000,000 in lost revenue.  If hospitals don’t figure out how to lower readmissions, it is going to cost them a lot of money.


Let’s take a look at what’s happening in Illinois with care transitions from the hospital.  The Illinois Transitional Care Consortium (ITCC) was formed to more effectively address needs of older adults transitioning from the hospital to the community by linking hospital based services with the aging network through intensive care coordination.  ITCC consists of 12 partners: community-based organizations, hospitals, a university research facility, and a policy and advocacy research organization.  ITCC developed the Bridge Model: a unique social work led model of transitional care that builds upon the Care Coordination Unit (CCU) system and Aging Network in Illinois.  ITCC is currently developing a proposal for funding through the Community Care Transitions Program (CCTP), described above. For more information on care transitions, please feel free to contact me, Kristen Pavle. This post was edited by Bridget Murtha, Chicago Bridge Blog Editor. Thank you to Nemo’s great uncle on for the photo.


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