Care Transition Program

CareCentrix is leveraging our expertise in home health care management to develop a new program, Care Transitions, that is designed to help health care plans and providers decrease avoidable hospital readmissions and other adverse medical events.

Studies show that home health care is effective at reducing hospital lengths of stay, lowering costs and improving patient satisfaction.  Research also suggests that 20-30 percent of hospital readmissions are preventable and another 30 percent ameliorable, if corrective measures are instituted earlier and more effectively.  As such, preventable readmissions can be considered symptomatic of defects in the delivery of care during hospitalization and/or in a member’s transition out of the in-patient setting to other sites of care.  According to recent studies, readmissions occur more frequently with certain diagnoses and procedures, and are frequently caused by:

• Medication errors Patient lacks instruction on new prescription or has difficulty getting it filled, or the new prescription may interfere with existing medication.
• Poor discharge planning Patient receives little or no information on how to achieve a successful recovery and/or does not schedule a follow-up appointment with their physician.
• Inadequate arrangements Family members or caregivers are uninformed or unable to provide the necessary care for transitioning the patient from the hospital to the home.
• Poor communication Delay in providing discharge summary to patient’s physician or not using a “teach- back” method to ensure patient understands self-care.

CareCentrix can help mitigate these issues by coordinating appropriate and timely home health interventions through our new Care Transitions program.  Studies reveal that improvements in discharge planning or new business models that apply interventions before, during and after discharge can improve member safety, and save the health care system upwards of $30-40 billion per year.

Through our Care Transitions program, we proactively enroll patients identified as high risk for adverse medical events into structured care plans that are delivered face-to-face in the home.  We leverage our expertise to partner with health care providers to identify members at risk for an adverse outcome, stratify that risk, and intervene to eliminate or ameliorate that risk.  In doing so, we help lower hospital spending and deliver improved patient outcomes over current medical management programs. 

CareCentrix is uniquely positioned to assist health care plans and providers with reducing hospital readmissions and adverse medical events through our new Care Transitions program. Contact us at to learn more.