Care Transitions Program Reduces Readmissions in Humboldt County

Together with St. Joseph Health System-Humboldt County and Humboldt State University's nursing department, the Community Health Alliance developed the Care Transitions Program to reduce hospital readmissions. Discharged patients who are not receiving home health or hospice care are assigned a coach who is a student nurse. Coaches meet patients in the hospital, visit them at home and then check in regularly in person or by phone at intervals up to six months after discharge. The coaches work with patients to review their medicines and check that they correspond with what the doctor prescribed, make sure they understand their disease and discuss how they can work with their doctor to manage their care. Special attention is given to patients at higher risk: those with chronic diseases; those with frequent readmissions who have five or more medications; and those who don't have access to home health care.

Since 2009, they've cut readmission rates from 10 percent to eight percent, a 20-percent improvement.