Community-Based Care Transition Programs


  • Catholic Charities Chicago, Illinois

Focus Area

  • Health

“Community-Based Care Transitions Programs leverage community-based organizations to help Medicare patients navigate the obstacles they face to recovery. They all have the same goal—to reduce 30-day hospital readmission rates by 20%. While their work is encouraging, we need to know what models of transition care actually improve the health and readmissions outcomes of patients.”

The Issue

Healthcare is costly. Thankfully, medical insurance helps to ease the burden. But if you have a disability, are over 65, or if you have a pre-existing health condition, finding affordable health insurance can be a daunting task. 

In 1965, the U.S. government responded to this challenge by establishing the Medicare program, which offers health insurance for Americans who are over 65 or have a disability. Today, over 17% of Americans rely on Medicare. That’s 56 million people. And while Medicare reduces healthcare costs significantly, beneficiaries are still required to pay $1,300 for each hospital stay and 20% of the bills they incur for physician care. 

For patients who are in and out of the hospital, these expenses add up. And they fall disproportionately on those with low incomes. In fact, low-income Medicare beneficiaries are more likely to spend over 20% of their annual income on uncovered premiums and healthcare expenses. Money that’s already needed for food, rent, and other basic necessities.

A 2017 report from the Commonwealth Fund finds that the average Medicare beneficiary spends over $3,000 on out-of-pocket medical expenses each year. And today, 45% of Medicare beneficiaries have incomes below 200% of the federal poverty level. In 2020, that’s an annual income less than $25,520 for a single person. This makes the $1,300 expense for each hospital visit an immense financial strain, especially because people with low incomes tend to suffer more acute health problems than the average American. Meaning longer, more frequent hospital visits. And more bills.

Frequent hospital readmissions are an expensive problem for patients, healthcare workers, and the government alike. Today, the number of readmissions a hospital incurs each year is often used as a proxy for the quality of healthcare services they provide. And now, the Centers for Medicare and Medicaid limit reimbursements for hospitals with readmission rates above a certain threshold. 

But for people in poverty—and for hospitals in low-income areas—readmissions continue to be common. Many patients experience setbacks following their discharge from the hospital, and many of these setbacks are for non-medical reasons. Patients in poverty do not always have the resources they need to schedule follow-up appointments or pick up and manage their prescriptions. They also don’t always have the social support they need at home to recover and maintain their health. And logistics can pose a major problem—accessing transportation to follow-up appointments or the pharmacy can be difficult. Some even have to decide whether their limited income should be spent on food or the medication they need. 

These barriers and hard choices lead to poor health outcomes—and oftentimes, a return to the hospital. With more expenses. It becomes a devastating cycle, keeping people in poverty and bad health.

But the Medicare Payment Advisory Commission estimates that 12% of hospital readmissions are avoidable. The Commission suggests that preventing even 10% of all hospital readmissions would save Medicare nearly $1 billion. 

To combat the high cost of hospital readmissions, the Affordable Care Act launched the Community-Based Care Transitions Program (CCTP) in 2012. CCTPs leverage community-based organizations to help Medicare patients navigate the obstacles they face to recovery. Across the country, over 72 sites are experimenting with various models of transition care. They all have the same goal—to reduce 30-day hospital readmission rates by 20%. 

While their work is encouraging, we need to know what models of transition care actually improve the health and readmission outcomes of patients. By understanding what works, we’ll be one step closer to reducing healthcare costs and improving the health and financial outcomes of everyone involved—especially those in poverty, who need their health and income the most. 

The Intervention

The Chicago Southland Coalition for Transition Care (CSCTC) is a CCTP program designed to reduce hospital readmission rates and help Medicare patients transition safely from the hospital to a full recovery. The program partners with four hospitals that serve patients in the Chicago Southland area. 

Participants are connected with a social worker, or transition coach, who helps to coordinate their transition upon their discharge from the hospital. Coaches visit with patients in the hospital, in their homes, and by phone to support them through their recovery. They provide guidance on proper nutrition and how and when to take prescription medications, and they help to schedule and organize transportation to follow-up appointments. Coaches also provide referrals to important community-based social and health services that can be valuable resources for recovery.

Research Question

Does helping Medicare patients manage their transition from the hospital to recovery improve their health outcomes and reduce the likelihood they’re readmitted?

Intended Outcomes

  • Hospitalized Medicare patients who are connected with a social worker through the CSCTC program will be less likely to be readmitted to the hospital following their discharge. They will also have better health outcomes.
  • With fewer readmissions, hospitals participating in the program will see reduced costs.

Research Study Design

The CCTP study is a retrospective analysis that compares the readmission rates of participating and non-participating patients in hospitals that offer the CSCTC program. 

Because Medicare Advantage patients are not eligible to enroll in the CSCTC program—though they’re largely the same as Medicare patients and are admitted to the hospital for many of the same reasons—LEO researchers compare the readmission and health outcomes for standard Medicare patients who participate in the CSCTC program with the Medicare Advantage patients who do not. 

This kind of statistical technique is called a difference-in-difference analysis and will help uncover the true impact of the program.  

Every three months, the Centers for Medicare and Medicaid provide 30-day hospital readmission rates for organizations that participate in CCTPs. Evidence suggests the Chicago Southland Coalition for Transition Care (CSCTC) CCTP program has reduced readmission rates among participating patients by 36%. Of the 72 CCTP sites offered across the country, this is one of the largest reductions in hospital readmissions. 

Still, LEO’s analysis provides more rigorous evidence of the program’s success by holding all factors constant. A preliminary analysis suggests the CSCTC program reduces 30-, 60-, and 90- day readmission rates by 19%. A simple cost-benefit analysis also suggests the program reduces readmission expenses by $100 more per patient than it costs to administer the CSCTC program. 

Since its launch in 2012, the CSCTC program has served over 11,000 patients.

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