Our Initiatives


Performing Provider System

Care Transitions to Reduce 30-Day Readmissions (Project 2.b.iv)


What do we hope to accomplish?

  • Strengthen continuity of care between NewYork-Presbyterian Hospital (NYP) inpatient care and subsequent settings in order to reduce the risk of avoidable readmissions within 30 days

Who is our target population?

  • Adult patients admitted to NYP hospitals who are readmitted, have a high readmission risk score, or deemed at-risk by their care team (psychosocial and medical determinants)

How will we do it?

  • Enhance care transitions services and collaboration with next level of care providers
  • Identify patients at high risk for readmission
  • Embed Transitions of Care Managers (RNs) who will work with patients and interdisciplinary care teams during inpatient stays and for 30 days post-discharge in order to:
    • Educate patients and caregivers on disease and self-management
    • Facilitate timely follow-up with primary care provider(s)
    • Coordinate medical and social service needs to overcome barriers to safe transitions
  • Employ Community Healthcare Workers who:
    • Collaborate with Transitions of Care Managers to facilitate and reinforce disease-focused education in a linguistically and culturally appropriate manner to patients and caregivers
    • Accompany patients to post-discharge follow-up appointments with primary care provider(s)
    • Assess non-medical causes of readmission, such as lack of transportation or food insecurity
  • Engage pharmacy supports to address patient pharmaceutical challenges
  • Utilize electronic health records and IT systems to share patient information and facilitate the transmission of care transitions plans to subsequent care settings

NY State Requirements

  1. Develop standardized protocols for a Care Transitions Intervention Model with all participating hospitals, partnering with a home care service or other appropriate community agency.
  2. Engage with the Medicaid Managed Care Organizations and Health Homes to develop transition of care protocols that will ensure appropriate post-discharge protocols are followed.
  3. Ensure required social services participate in the project.
  4. Transition of care protocols will include early notification of planned discharges and the ability of the transition case manager to visit the patient in the hospital to develop the transition of care services.
  5. Protocols will include care record transitions with timely updates provided to the members’ providers, particularly primary care provider.
  6. Ensure that a 30-day transition of care period is established.
  7. Use EHRs and other technical platforms to track all patients engaged in the project.

Scale and Speed

Metric: The number of participating patients with a care transition plan developed prior to discharge.

Scope of Intervention: The Care Transitions workflow will be inclusive of dual-eligible Medicaid and Medicaid Managed Care patients with a high risk stratification score and/or an unplanned readmission. The Care Transitions team may prioritize adult patients age 18+ with the following chronic diseases or factors in its approach:

  • Acute Myocardial Infarction (AMI)
  • Asthma
  • Behavioral health
  • Chronic Heart Failure (CHF)
  • Chronic Obstructive Pulmonary Disease (COPD)
  • Diabetes
  • Social determinants of health
  • Polypharmacy (10+ medications)
  • Pneumonia
  • Renal failure
  • Respiratory Infection

Commitment: Through DSRIP Years 1-4, the target number of actively engaged Care Transitions patients is per below:

  • Year 1 (4/1/15-3/31/16) – 150 patients
  • Year 2 (4/1/16-3/31/17) – 1,269 patients
  • Year 3 (4/1/17-3/31/18) – 1,904 patients
  • Year 4 (4/1/18-3/31/19) – 2,538 patients

Note: A discharge needs to be accompanied by a Care Transitions plan in order for that patient to count as ‘actively engaged’.

Note: A patient may not count toward the actively engaged goal more than once in a DSRIP year.