Project 2.b.iv – Care Transitions Intervention Model to Reduce 30 day Readmissions for Chronic Health Conditions

Why FLPPS Chose this Project

A significant cause of hospital readmissions, is a patient’s lack of understanding of their medication regimen and discharge plan.  This may be a result of many factors including health literacy, language issues, and lack of engagement with the community healthcare system. Improved Cultural Competency and Health Literacy throughout our Partnership will be integral to the success of this project. Within the Finger Lakes region, coordination of care may be fragmented, and lack of overall management of chronic health conditions pose a gap in care leading to high readmission rates.

As part of the FLPPS Community Needs Assessment, stakeholders cited gaps in health literacy, particularly around patient understanding of their disease(s) and the role of medications in disease management. Patients cited medication adherence issues, including confusion around the need for multiple medications, and medication non-compliance due to the inability to fill prescriptions after hospital discharge. Furthermore, patients lack access to basic necessities, adequate support networks and resources to attend to complex health needs.


An area of focus are individuals with a primary diagnosis of COPD, diabetes, CHF, cardiovascular disease, ischemic heart disease or pneumonia.  The following primary diagnoses have been linked to higher risk for hospital readmission: chronic obstructive pulmonary disease (COPD), diabetes, congestive heart failure (CHF), cardiovascular disease, ischemic heart disease or pneumonia.



What Success Looks Like

A 30-day supported transition period after hospitalization to ensure discharge directions are understood and implemented by patients with high risk of readmission. A transition case manager or other qualified team member work one-on-one with the patient to develop a care plan.  The care plan will include information on provider appointments, medication regimen, and community resources available to support the patient in their home.