Partners in Care Foundation, a community care hub (CCH) in Sacramento, California, presented on their care transitions program during the May 10th, 2023, CCH National Learning Community (NLC) Network Development Peer Group Dialogue Meeting. They have had success in reducing hospital readmissions (10.2% readmission rate vs California average of 18.5%) though an effective transitions to home program that keeps patients out of the hospital, maximizes HEDIS quality measures and protects Medicare Advantage Star quality ratings.

Here are a few key points from their presentation:

• Combining tools—such as HomeMeds, CTI, Bridge, etc. – allows for the development of an individualized social care plan with the case manager
• HomeMeds intervention addresses adverse events related to medications though medication reconciliation and risk assessment in every care transition intervention
• Using Social Workers or Community Health Workers instead of licensed staff allows the cost to be kept down and lets licensed staff work where they are most needed
• Program staff from the community builds trust with people served, which translates to better outcomes

The slides are available here and include a contact for questions or more information.