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Impact of a Scalable Care Transitions Program for Readmission Avoidance

Resource Type: Research Papers

The Care Transitions Solution (CTS) is a Texas Health Resources structured readmissions reduction program with foundations in 1) risk stratification, 2) optimization of community resources, 3) clear, consistent communication and 4) individualized post-acute efforts. This study retrospectively examined the impact of CTS at 14 acute care facilities for several conditions, including COPD. Those in the treatment group (subjects with all studied conditions who received CTS supports) were 25% less likely to be readmitted to acute care within 30 days.

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Hamar B, Rula EY, Wells AR, Coberley C, Pope JE, Varga D. Impact of a Scalable Care Transitions Program for Readmission Avoidance. Am J Manag Care. 2016; 22(1): 28-34.Published January 20, 2016. Accessed March 14, 2016. Accessed March 12, 2020.

care coordination evaluation & quality improvement readmission

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