Care Transitions Achieving Better Health Outcomes

Project Term: 24 months; 2016-2018
Grant Amount: $135,250

This grant will support a care coordination position to help older adults transition successfully from hospitals back to their homes, with a focus on dual-eligible Medicare and Medicaid patients. This group of patients tends to utilize high-cost services such as inpatient care more frequently than the general population, and social risk factors such as poor housing and social isolation often lead to poor clinical outcomes. The project will use an established model that involves home visiting followed by frequent phone or in-person contacts during the month after a hospital stay. The program will also identify social risks and help coordinate appropriate referrals as needed. This project builds on a current effort funded by the Center for Medicare and Medicaid Services which has been shown to reduce hospital re-admissions and reduce health care spending.

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