Building a care transitions model with a CCTP for high risk patients

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Building a care transitions model with a CCTP for high risk patients

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Hallmark Health System, Mystic Valley Elder Services, Somerville-Cambridge Elder Services and Cambridge Health Alliance developed a program to enhance existing discharge practices and patient care at multiple service locations.

The Issue

We struggled to reduce readmissions and provide a better experience for the patients in this high-risk, elderly population.


Location-Medford and Melrose, Massachusetts.

Type- Acute care community hospitals.

Number of Beds-400.

Population served- High risk patients.

Hallmark Health System is a network of medical and health centers, which includes two community hospitals with a total of 400 beds.

What We Tried

In partnership with Mystic Valley Elder Services, Somerville-Cambridge Elder Services and Cambridge Health Alliance, we implemented a community-based care transitions program (CCTP). The CCTP is supported by CMS and tests models of care by targeting patients’ transitions from the inpatient hospital to other care settings. The overall goal of the program is to meet the CMS goal of a 20 percent reduction in readmissions.

In our program, acute care nurses review patients who were admitted to the acute care setting at multiple points in time and then collaborate with their community partners to coordinate the patients’ care plans. The community team members include the transition facilitator, case manager, nurse practitioner, visiting nurse and pharmacist.

Interventions that were key to the success of the CCTP team included:

-Analysis of the reasons for admissions

-Development of a plan based on the data

-Implementation of a transition facilitator and a community-based nurse practitioner role

-Completion of an acute care assessment of patients on admission, including a high-risk analysis to determine eligibility for enrollment

-A pre-discharge meeting between the patient and care transition facilitator for coordination of needs and resources

-A post-discharge visit by the transition facilitator within three days; 30 days of continued follow-up including a home-based assessment by a community-based nurse practitioner


Measured progress has been made toward the program goal and the CMS-prescribed goal of a 20 percent reduction in hospital readmissions in high-risk groups (see table 2 below). This program has been identified as fourth among the 48 Community-Based Organizations for decreasing the readmission rate by 11 percent thus far.


In order to allow the transitions program to be developed with an individualized and specific intervention, it is important for health systems to include a preliminary analysis to determine the root cause of readmissions specific to their populations. We also recommend including community-based partners as the primary team members. Embracing the community-based staff as part of the transitions team will ensure a smoother, more efficient transition to each patient’s post-acute destination.

Organizational Background

Organization Name: Hallmark Health System

Location: 170 Governors Avenue, Medford, MA, United States

Organization Type: Hospital