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Care Transitions Collaborative Aims to Eliminate 8,700 Hospital Readmissions, Save $80 Million Dollars

Thousands of Colorado patients will benefit from an unprecedented collaboration that coordinates providers, patients and communities around the state in a joint effort to keep patients healthy once they leave the hospital. The two-year initiative, Healthy Transitions Colorado (HTC), aims to eliminate 8,700 hospital readmissions across the state, save Coloradans $80 million in health care dollars, and collectively help patients avoid an extra 34,000 days in the hospital.

Healthy Transitions Colorado focuses on aligning and accelerating existing efforts to improve transitions of care from health care settings to home or other care settings to avoid hospital readmissions. Hospital readmissions are often the result of incomplete or ineffective communication and a fragmented health care system. For example, without careful consideration, a patient leaving the hospital after having heart surgery may not completely understand their condition and new treatment regimen, which can result in medication mix-ups or other care management gaps and an unplanned trip back to the hospital. Healthy Transitions Colorado coordinates the tools, resources and efforts of many partners across the state to reduce fragmentation and ensure patients get the care and follow-up they need. The campaign will help propel existing efforts to not only save millions of dollars, but also to significantly improve the overall health and quality of care provided to patients.

“Colorado has become national leader in reducing the number of Medicare patients that need to be readmitted to the hospital,” said Colorado U.S. Senator Michael Bennet, keynote speaker at the HTC launch event who helped expand the Colorado-based Care Transitions model nationwide in the Affordable Care Act. “The Healthy Transitions Colorado initiative will continue to demonstrate that a strong coordinated care network can lead to better results at a lower cost.”

Jonathan Blum, Acting Director of the Centers for Medicare & Medicaid Services (CMS) testified before the Senate Finance Committee earlier this year that for the first time in five years, CMS is seeing a reduction in hospital readmission rates indicating early signs that hospital readmission penalties and payment and delivery reform may be having a positive effect on the system. Colorado has also seen small-scale community improvements in readmission rates by using proven methods such as Eric Coleman’s nationally utilized Care Transitions Intervention ®.

Jane Brock, MD, MSPH, Chief Medical Officer for Community Action for CFMC, an HTC operating partner and national coordinator for care transitions programs, indicated that reducing readmissions isn’t easy, but real momentum occurs when a community engages around a common goal. “It takes a community working together to make sure patients have everything they need to stay healthy – access to follow up care, ability to fill and take medications, and even basic things like food in the pantry. This initiative brings more awareness and momentum to help communities engage key health and social service providers in this important work.”

Center for Improving Value in Health Care (CIVHC) manages Healthy Transitions Colorado in tandem with four operating partners: the Colorado Hospital Association (CHA), Colorado Rural Health Center (CRHC), Colorado Health Care Association (CHCA) and CFMC, the Medicare Quality Improvement Organization for Colorado. These organizations help their constituents – hospitals, providers, long-term care facilities, community partners, and more – improve care for patients in their community and keep them healthy. Each operating partner has committed to providing time, resources and expertise to support the initiative.

Over 40 additional Colorado organizations have supported the development and implementation of HTC by participating in the task force leading up to the launch. “Health care leaders across Colorado identify effective patient transitions as a common sense, high impact focus area to improve the effectiveness of our health care system and bring down costs,” said Phil Kalin, CIVHC President and CEO. “When we began convening the care transitions task force over a year ago, it became clear that we needed to pull Colorado initiatives together to create common goals and provide a platform for learning and sharing across the state.”

Healthy Transitions Colorado is encouraging anyone interested in supporting care transitions in their community to sign the community pledge available at Participation is free, and by signing the pledge, organizations can publicly demonstrate their commitment to improving the lives of Coloradans, join a statewide effort to reduce readmissions, and gain access to valuable educational resources and support. Throughout the campaign, HTC will provide educational resources and linkages to communities across the state to advance care transitions programs locally.

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