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Excellence in Population Health

A Successful Community-Based Care Transitions Program Model

Warren, Cheryl, MSN, RN; Lemieux, Amy A., PharmD, BS; Phoenix Bittner, Nancy, PhD, CNS, RN

doi: 10.1097/NCM.0000000000000303

Purpose/Objective: The Community-based Care Transitions Program (CCTP) defined a broad spectrum of interventions and services for elderly patients at high risk of hospital readmission. The purposes for a CCTP as developed by the Centers for Medicare & Medicaid Services are to improve transitions of beneficiaries from the inpatient hospital setting to other care settings, to improve quality of care, to reduce readmissions for high-risk beneficiaries, and to document measurable savings. The goals for this CCTP initiative were as follows: achievement of a 20% reduction in the 30-day all-cause readmission rate across all partner hospitals compared with baseline; reduction in the 30-day all-cause readmission rate among the high-risk cohort served; and achievement of the target volumes for full enrollment.

Primary Practice Settings: The partnership included acute care institutions and community-based care organizations that have been involved with care transition programs for years and have a long history of working collaboratively to provide services to a largely low-income, underserved, and ethnically and racially diverse target population.

Findings/Conclusions: The program successfully transitioned to full operation within the first year of inception. To date, the partnership of the acute hospital setting and the community-based organizations has reached and provided services to nearly 8,000 total individuals, surpassing our target enrollment goal. To date, the readmission rate has decreased to 12.5%, which is an 11% decline since inception of the program.

Implications for Case Management Practice: The collaboration of health care providers, social workers, nurse practitioners, physicians, community pharmacists, and the visiting nurses is integral to a successful transition from hospital to home. Home visits by the transition facilitators allowed for the coordination of a multitude of services in the community, including those previously available to patients in the past that have rarely been accessed. Including a pharmacist on the team provided teaching regarding medication adherence, medication management, and pharmacy services, which added to interventions to decrease future hospitalizations.

Cheryl Warren, MSN, RN, is currently the Chief Clinical Integration Officer at Hallmark Health System, Medford, MA, with responsibility for Ambulatory Services, Case Management, Utilization Management, and Social Work, as well as strategic planning for transitions of care in the post-acute community. She has 14 years' experience in nursing leadership, specializing in case management.

Amy A. Lemieux, PharmD, BS, is a pharmacist focusing on Transitions in Care at Hallmark Health System, Medford, MA. She is an adjunct faculty member of MCPHS University and WNEU College of Pharmacy. Amy was previously a clinical supervisor at Hallmark Health System and prior to that a clinical pharmacist at McLean Hospital.

Nancy Phoenix Bittner, PhD, CNS, RN, is Vice President for Education at Lawrence Memorial/Regis College Nursing and Radiography Programs and Research Scientist at Hallmark Health System, Medford, MA. Her program of research is focused on cognitive processing nursing practice. She has had several research publications and presentations related to her research nationally and internationally.

Address correspondence to Nancy Phoenix Bittner, PhD, CNS, RN, Hallmark Health System, 170 Governors Ave, Medford, MA 02155 (

The authors report no conflicts of interest.

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