Office for the Aging


Care Transitions Help Reduce Hospital Readmissions and Save Money

Care transitions refer to the shift experienced by individuals from one provider or setting to another (e.g., from hospital or home or nursing home, or from a facility to home with services and supports). During the course of an illness, an older adult may receive care in multiple settings, which can lead to confusion due to the lack of information that is transmitted and poorly implemented post-discharge care plans. Older adults experiencing care transitions are vulnerable to issues such as medication discrepancies, lack of follow-up, and so forth.

Each year, approximately 2.3 million older adults are readmitted to the hospital within 30 days of being discharged. These readmissions represent a cost of over $26 billion every year. Research on care transitions activities has shown that patients receiving such an intervention have lower rates of re-hospitalization and have shown significant reductions in Medicare costs. Safe, effective, and efficient care transitions require thoughtful collaboration among health care providers, hospitals, nursing homes, home and community based organizations, caregivers, and consumers themselves.

The Aging Network plays an essential role in ensuring safe care transitions for older adults. The New York State Office for the Aging (NYSOFA) became involved in the facilitation of care transitions as a result of a 2009 Aging and Disability Resource Center (ADRC) grant. As part of this grant, NYSOFA initiated the development of a Community Supports Navigator (CSN) program in two pilot counties (Albany and Tompkins). The program, administered in partnership with St. Peters Health Partners (formerly Northeast Health) and Community Caregivers Inc. (a not-for profit volunteer recruitment and placement agency for older adults), offered assistance to individuals during their transition from hospital to home with the goal of reducing unnecessary or preventable re-hospitalizations. The CSN used specially trained volunteers as care transition coaches for a period of 90 days to provide additional support with non-medical tasks such as attending follow up appointments and physician visits, linking with appropriate community services through NY Connects, medication self supports, improving the patient's health literacy, and offering the consumer and caregiver support as needed.

In 2010 NYSOFA was 1 of 16 State Units on Aging to receive an Evidenced-based Care Transitions program grant from the Administration on Community Living (ACL). This grant enabled NYSOFA to enhance the existing Care Transition Intervention CTI) in Albany County by creating a "CTI Plus" program that: 1.) expanded the CSN's target population and 2.) formalized the connection to Albany NY Connects to assist with linkage to available long term services and supports.

Care transitions programs generally serve at-risk older adults who are diagnosed with one or more chronic conditions, such as: heart disease, hypertension, chronic obstructive pulmonary disorder, diabetes, and so forth. Caregivers can also benefit from care transitions programs if the consumer lacks the capacity to manage their condition independently, or if the caregiver needs additional support.

NYSOFA is committed to promoting the importance of the aging network in care transitions interventions. As part of a 2011 Systems Integration grant from ACL, participating NY Connects programs are required to, at a minimum, identify active care transitions programs in their locality. In addition, through the 2012-2013 NY Connects contract, all NY Connects programs are required to establish referral protocols with local hospitals and critical pathways to support care transitions activities. Moreover, several Area Agencies on Aging/NY Connects programs are either facilitating care transitions or acting as key partners in the Affordable Care Act's Section 3026 Community-based Care Transitions Program (CCTP), which promotes collaboration between hospitals and community based organizations by offering Medicare reimbursement for successful care transitions.

Care transitions require strong partnerships and communication between hospitals and medical practitioners and the network of home and community based care. The CSN initiative administered by NYSOFA involved a partnership between Albany and Tompkins County NY Connects, St. Peters Health Partners (Albany County), Cayuga Medical Center (Tompkins County), Community Caregivers (Albany County), and Project Care (Tompkins).

The Section 3026 CCTP initiatives involve several partnerships with medical organizations and key home and community based stakeholders, including, but not limited to: the P2 Collaborative of Western NY, the Finger Lakes Health Systems Agency, Visiting Nurse Service of Schenectady and Saratoga Counties, Fort Drum Regional Health Planning Organization, St Peters Health Partners, and so forth.

There are Section 3026 CCTPs operating throughout New York State. These programs began at different points throughout 2012 and will operate for a period of 1 to 3 years, depending on the success of the program. The following programs have been approved by the Centers for Medicare and Medicaid Services (CMS):

  • -Brooklyn Care Transition Coalition
  • -Eddy Visiting Nurse Association (Albany, Rensselaer, Columbia, Greene)
  • -Isabella Geriatric Center
  • -Lifespan of Greater Rochester, Inc. (Monroe, Wayne, Ontario, Livingston)
  • -Mt. Sinai Hospital
  • -North Country Community-based Care Transitions Program (St. Lawrence, Lewis, Jefferson)
  • -P2 Collaborative of Western NY (Chautauqua, Cattaraugus, Allegany, Genesee, Orleans, Wyoming)
  • -Queens Care Transitions Collaborative (NYC Department for the Aging)
  • -Tompkins County Office for the Aging
  • -Visiting Nurse Service of Schenectady and Saratoga Counties, Inc (Saratoga, Schenectady, Warren, Montgomery, Fulton, Franklin, Essex, Clinton)

For more information on the different CCTPs operating in New York State, visit the Centers for Medicare & Medicaid Services.(External Link)

To learn more about NYSOFA's Community Supports Navigator initiative, watch our video(External Link)

For additional information on Care Transitions, contact Amy Hegener at 518-408-1856 or email .