Community Coalition to Improve Care Transitions

bigstock-Nursing-home-5696886Care transitions are the process that people go through as they move from one care setting—such as a hospital or acute care facility—to another setting, such as the person’s home. Over the course of an illness, a person may experience multiple care transitions. Coordinating care across these transitions is a vital step in reducing preventable hospital readmissions.

The PCC brought together a number of community partners to form the Community Coalition to Improve Care Transitions. The coalition is improving the transition of care from hospital to community, thereby reducing preventable readmission to acute care hospitals. Over the next three years, the coalition aims to reduce preventable readmissions by 20 percent.

To begin, the Coalition is focusing on a small population of individuals with complex health conditions who live in Holly Hall public housing facility operated by the Housing Opportunities Commission (HOC). The Coalition is providing care coordination to patients who are eligible for both Medicaid and Medicare—frequently referred to dual eligible—as they are discharged from Washington Adventist Hospital to return to their homes in Holly Hall.

The people receiving services through this program are low income—55 percent have annual incomes below $10,000—and have substantial health needs resulting from conditions like diabetes, stroke, dementia, chronic obstructive pulmonary disease , and mental illnesses. Most of the program participants require help with three or more activities of daily living.

The Coalition members are working together to reduce unnecessary hospital readmissions, inappropriate emergency department use, and to empower patients to take control of self-management by:

  • Providing care coordination to assess barriers to appropriate care and identify solutions to ensure access
  • Evaluating patient’s ability to perform daily tasks and meet basic needs
  • Assessing the ability of family members and other informal caregivers to help patients
  • Educating patients about the importance of self-management and fulfilling their individual care plans
  • Helping patients to use effective coping strategies to manage problems

For more information contact Mary Joseph at 301.628.3458 or