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2.b.iv: Care Transitions Intervention Model to Reduce 30-day Readmissions for Chronic Health Conditions

Project Objective: To provide a 30-day supported transition period after a hospitalization to ensure discharge directions are understood and implemented by the patients at high risk of readmission, particularly patients with cardiac, renal, diabetes, respiratory and/or behavioral health disorders.

Project Description: A significant cause of avoidable readmissions is non-compliance with discharge regiments. Non-compliance is a result of many factors including health literacy, language issues, and lack of engagement with the community health care system. Many of these can be addressed by a transition case manager working one-on-one with the patient to identify the relevant factors and find solutions. The following components to meet the three main objectives of this project, 1) pre-discharge patient education, 2) care record transition to receiving practitioner, and 3) community-based support for the patient for a 30-day transition period post-hospitalization. Additional resources for these projects can be found at and


PMO: Suehane Sanchez

BLHC Project Lead: Natalie Cruz, RN & Reena Agarwal, MD

Sep 30, 2016

Project update for September 2016

A new Care Transitions RN has been hired.  In this role, the Care Transition RN will be working with patients identified as high-risk for readmission to create a care plan prior to discharge.  The Care Transitions team, in concert with Partner organizations in the community, continues to work with patients post-discharge to ensure patients have appropriate support services to maximize both health and psycho-social support.


In the High Utilizer pilot study, over 30 High Utilizer patients have presented to the Bronx Lebanon ED/Inpatient hospital and over 50% have been engaged through the Care Transitions team and referred for community-based services (e.g. Doctors on Call; Outpatient Psychiatry; Detox/Rehab services; etc.).  Secure message alerts are received daily by the Care Transitions for High Utilizer patients.  A Care Manager from Healthfirst is also supporting the Care Transitions team and documenting care coordination efforts in Allscripts (patient EMR) to better coordinate Care Coordination efforts.