Transitioning Patients From the Hospital Back to the Community

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Transitioning Patients From the Hospital Back to the Community

< 1 minute read

Sharp Grossmont Hospital created a case management model to help manage 30-day readmissions.

The Issue

Transitioning patients safely from the inpatient setting to the next setting can be challenging even to the most seasoned of case managers. Sharp Healthcare in San Diego, California is committed to ensuring that our patients go to the next level of care on the correct care pathway. We were given the opportunity to participate in the Community based Care Transitions Program (CCTP), through a grant from CMS to work with other hospital systems and our community-based organization Aging and Independence Services.

What We Tried

Using the 30-day Care Transitions Model® by Eric Coleman, we achieved significantly lower readmission rates for patients who participated in the program. This intervention involves a home visit and 2-3 follow-up phone calls over a 30-day period. Based on this model, Sharp Grossmont Hospital (SGH) extended this program to include patients with specific challenges, including inadequate or no insurance coverage; co-occurrence of multiple, complex chronic health conditions (diabetes, cardiovascular disease, etc.); and lack of social support or isolation for those who live in San Diego’s east region.

Based on our experience, we implemented two major changes that we felt had limited the CCTP program in working with this high-risk population.

  1. We allowed for repeat enrollment in the program (instead of limiting CCTP to one enrollment every 6 months),
  2. We allowed patients to receive coaching for longer than 30 days if needed. No patient has exceeded 60 days of coaching services at this point.

In addition, SGH developed unique solutions to keep patients safe and self-managed in the community as well as lowering readmission rates. SGH initially targeted the highest risk patients based on a homegrown risk assessment tool, but with time, various payers developed their own programs that enabled the team to concentrate on the truly vulnerable patient population, including Medi-Cal pending/presumptive, self-pay, no pay, refugees, homeless, and Medicare A or B-only patients.

The SGH transitions program enhances patient home safety by reviewing medications, facilitating early recognition of symptoms, establishing a medical home, providing advanced care planning choices, implementing pharmacy support and specific care management plans across the care continuum. Part of this is accomplished by connecting patients to community resources to maintain their health and safety, including food (directly), hunger relief organizations, transportation resources, access to a primary care physician for follow-up care, medical equipment, and other social supports.


With backing from the hospital foundation, various community businesses and individual donors, partnerships with Feeding San Diego (America) and 2-1-1 San Diego were successfully established in CY 2016. As a result, the program has been able to support patients by providing food, medical supplies (blood pressure cuffs, diabetes kits, pulse oximeters, pill boxes) and assistance with co-pays for medications as needed. The CTI® team has also connected with other hospital-based programs for support and leadership. The team is one of the primary referral sources for the various specialty navigation programs, case management, and social workers.

Readmission rates for this team have dropped significantly, and much further than expected. Overall, the readmission rates for CY 2016 so far average 8% through the end of October 2016. Readmission rates for same type/eligible patients during same time period who refused services is 19%.


Connecting and communicating all these pieces is where the art of managing these patients lies. Electronic data support is essential to success in not only transitioning hospitalized patients between services and departments, but enables hospital-based staff to connect and keep track of patients after they are back in the community. Sharing patient information with community organizations (with consent of the patient) enables all parties to meet the patient needs and ensure collaboration between services. The throughput of data in one place-from admission to post-discharge-engages all parties to ensure services are rendered (without overlap) and achieve appropriate outcomes.

From assessing patient risk, to filtering eligibility lists of patients based on insurance, to accessing services within the hospital and outside-then adding the ability to report patient activity back to hospitals and analyzing the root cause of readmissions-this is the motor that drives the program to success. The entire continuum of the process for the patient is contained in one space in the EMR.

Organizational Background

Organization Name: Sharp HealthCare

Location: 8695 Spectrum Center Blvd, San Diego, CA, United States

Organization Type: Hospital