Woodbury, N.J., High-Risk Seniors Avoid Hospital Readmissions Through a Care Transitions Program

Improving transitions in care from hospitals to other settings

    • May 15, 2014

Dates of Project: July 2011 through June 2013

Description: The Care Transitions Program focused on high-risk patients aged 65 years and older who had been discharged from the hospital in the previous 30 days, or who had six or more hospital admissions in the previous 12 months.

A key component of the program was a care transitions coach—a registered nurse who worked with other health care facilities to oversee patients’ transitions to those facilities, and to educate patients and their caregivers about managing the patient’s own health.

Key Results

  • According to a report to RWJF and an interview with project staff:

    • Just 26.5 percent of 585 patients who participated in the program from November 2011 to December 2012 were rehospitalized within 30 days after discharge.
    • The number of patients rehospitalized within 60 days of discharge fell by 59 percent (from 694 to 284), compared with hospitalizations among patients before they participated in the program.
    • The number of patients who were readmitted to the hospital twice within 60 days after discharge dropped by 61 percent (from 118 to 46), compared with hospitalizations among patients before they participated in the program.
    • The number readmitted three times within 60 days after discharge declined by 75.7 percent (from 33 to 8).

“For us, the program has had a big impact. It saves us the huge costs associated with readmissions. But even more important, it allows Inspira to better fulfill its mission of providing high-quality health services that improve the lives of our patients.”—Denise Campo, RN, MHA

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