At-a-Glance: Care Transitions Program Overview
Referrals & Member Enrollment: Participants are referred to the program at the time of admission to a facility with a defined diagnosis that meets program inclusion criteria. The health coach then performs an in-person evaluation of the member.
Enrollment Timeframe: Members enrolled for 45 days post facility discharge.
Diagnoses Covered: Diabetes, heart failure, COPD, acute myocardial infarction, pneumonia, total joint replacements, and stroke.
Mode of Care Coordination: In-person and telephonic outreach.
Clinical Quality Measures: HEDIS standards of care related to covered diagnoses.
Outcome Measures: Overall reduction in 30 day readmissions, both all-cause and diagnosis specific.