Returning home from the hospital after an acute event can be complicated, and reducing unnecessary hospital readmissions requires a comprehensive approach that addresses the whole person. That’s why our Post-Acute Care Readmissions Management program relies heavily on engagement from our Care Transition Team, which includes social services coordinators and nurse coaches who help address and advocate for members on a wide variety of medical and social needs.

Watch the video below to hear our Chief Medical Officer, Dr. Carmella Sebastian, speak with CareCentrix Social Services Coordinator Michelle about her role in the Care Transition Team. Learn more about the barriers members face and how Michelle addresses member SdoH needs by connecting them to community resources.

Our Care Transition Team includes physicians, nurses, social services coordinators, and patient advocates to support member transitions home, which provides meaningful outcomes for payors:

  • 22% reduction in unnecessary hospital readmissions over 90-day program2
  • 20% annual savings on unnecessary readmissions spend2
  • 95% medication reconciliations completed within 30 days2
  • Potential positive impact on Stars and HEDIS® measures, including Transitions of Care3

Learn more about reducing unnecessary readmissions on our Post Acute Care: Readmissions Management Program page.


Reducing Unnecessary Readmissions through Whole-Person Care – Video Transcript:

00:00:06:06 – 00:00:17:13
Dr. Sebastian
So. Hello, everyone. I’m Dr. Carm, the Chief Medical Officer of CareCentrix. CareCentrix is focused on helping our patients on their best path to recovery. You’d be surprised to know that 32 percent of our patients require some sort of community or social support for optimal healing. And I am so lucky today that I am with one of our exceptional social workers, Michelle.

00:00:17:23 – 00:00:33:06
Dr. Sebastian
Hi, Michelle. Hello. Hi. Welcome. I understand, Michelle, that you work with our patients and you develop and implement a personal care plan for them. Is that, right?

00:00:35:12 – 00:00:50:21
Yes. Yes. That is correct. I receive referrals from the nurses with the PAC program, and they let me know what some of the challenges are that the patient is having, and then I step in and help assist so that the patient can heal at home.

00:00:51:18 – 00:01:21:19
Dr. Sebastian
That’s wonderful because home is the best place to be when you’re not feeling your best. I always find that. And, you know, give us an idea of some of the things that you help with. I know that a lot of buzz right now is social determinants of health. Can you tell us a little bit about what they are and how you may use them to help patients?

00:01:21:19 – 00:01:46:22
Some of the challenges that the patients face is transportation. A lot of times with their, with the benefit that they have through their health program, their health plan, it has a limited number of transportation round trip trips that they can have. And patients who go to dialysis, for example, three times a week, they utilize those days are up quickly.

00:01:46:22 – 00:02:16:10
So I have to find an alternative transportation mode for them. And a lot of times, I’m able to find a para-transit service, which is curbside transportation. They come to the home and get the patient, but in many cases, that is a $6 round trip. So that’s $18 a month for the patient, I mean, a week for the patient. And that’s just, you know, four weeks out of the month, it becomes an impossibility for them. So sometimes, that’s a challenge.

00:02:16:24 – 00:02:25:24
Dr. Sebastian
Sure. Tell me, tell me a little bit more about your role. What are some of the other things that you find yourself doing with patients?

00:02:26:10 – 00:02:51:13
We have patients dealing with shut-off notices for their utilities, and they’re oxygen-dependent, or they, you know, it’s winter, they need the heat. So I just advocate, I contact the utility company, I contact other community agencies and try to network with them to have the patient’s service either resumed or not to turn it off.

00:02:52:07 – 00:03:18:23
Dr. Sebastian
Mm-hmm. So basically, it’s very, very difficult for patients to heal when they don’t have some of these basic services. If you can’t get to your doctor, it’s very hard for you to have a good healing process if you need to see your physician. What about medications? I know that’s another thing that sometimes patients have a problem either paying for or having access to.

00:03:21:19 – 00:03:53:03
A lot of their medications, they’re not able to pay for the co-pay for office visits. And as a result, they just miss the appointment. Either they don’t go, or they don’t pick up their medication because they just cannot afford to. And then I get involved and try to see if there’s a formulary of a generic form, perhaps. Or I’ll call the doctor’s office and ask can they get the patient samples while we’re waiting to find another form of medication for them and that, that helps a lot.

00:03:53:03 – 00:04:21:17
And for prescriptions, a lot of times I’ll go right to the manufacturer and go and look online for their patient assistance program. And with enough information about the patient’s income, they may qualify for the program and be able to receive some of the medication, either at no cost for a year or at a very, very reduced cost.

00:04:22:17 – 00:04:37:16
Dr. Sebastian
That’s, that’s amazing. Are there any case or patient journey that sticks out in your mind that you’d like to tell us about so we can understand a little bit more about this?

00:04:37:21 – 00:05:06:15
Um, I had one patient in particular who, he was living in a motel that was his house. He had been there for like three years, but the weekly rate was something that was affordable. But along the way he just had some chronic conditions and he needed a motorized wheelchair because he was catching the bus different places and the manual chair, he just wasn’t able to maneuver it as well anymore to the bus stop.

00:05:07:02 – 00:05:25:13
So I was able to go to Cancer Care, which is a program that, if you qualify, you can get grants where, and you can use the grants for things that you may need. And I also worked with Hoveround to give them a motorized scooter, a motorized wheelchair, and that worked out beautifully for him.

00:05:25:18 – 00:05:32:00
He received the check in the mail. He got the wheelchair, and he was back. You know, he was back in action.

00:05:32:00 – 00:05:34:19
Dr. Sebastian
So, Michelle, you have another patient you’d like to tell us about?

00:05:36:11 – 00:06:00:17
Yes, there is another patient. She was a young woman, I believe she was 30 or 31, and maybe a couple of years prior, she had injured her foot at a party, at an event, and she never went to the hospital to have it addressed in the foot swelled, and by the time she made it to the hospital, the foot had to be amputated. Her leg had to be amputated.

00:06:01:02 – 00:06:33:11
And so now she’s living in her apartment. She couldn’t really get around as well as she had before, and I was able to contact the rehab facility in her community, and they were able to get her on service and fit her for a prosthetic leg, and that changed her life. She was able to stay in her apartment. She was able to stand again at the stove and cook and just live her life in a more, in a manner that she had before she was sick.

00:06:33:20 – 00:06:40:07
And that was just it was really, really heartwarming to see that happen for her because she was so young.

00:06:40:16 – 00:06:45:08
Dr. Sebastian
Yeah, amazing. Totally changed her life.

00:06:45:08 – 00:06:47:24
It did, it changed their life in a big way.

00:06:49:09 – 00:07:04:07
Dr. Sebastian
That’s wonderful. Well, I really appreciate your being here with us today, and I just want to say thank you so much. I know the patients appreciate you. We appreciate you very, very much. So thank you for all you do for CareCentrix and the patients.

00:07:05:04 – 00:07:08:18
Oh, it’s my pleasure. I love what I do, and I love this company.

00:07:09:11 – 00:07:10:00
Dr. Sebastian
Thank you.

  1. Measure Specifications: Potentially Preventable Hospital Readmission Measures for Post-Acute Care. 2015 2. Costs & Outcomes Assessment of Post-Acute Care Intervention. Avalere. 2021 3. Based on CareCentrix Internal Data Analysis 2022