Hospital Transition Program


  • Cabell-Huntington Hospital, West Virginia
  • St. Mary's Medical Center, West Virginia
  • Wheeling Hospital, West Virginia

Focus Area

  • Health

"Our goal at the end of that six weeks is really to have a person in a place where they can maintain their health and their safety at home at a higher level than they were able to before hospital admission, so that they have that stability for the long term."

Sara Lindsay, Chief Operating Officer, Catholic Charities West Virginia

The Issue

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. This problem is particularly damaging in West Virginia—a state with a high rate of poverty and in comparison to other states, has the highest rates of many poor health categories 

As the largest social service provider in the state, Catholic Charities West Virginia (CCWVa) is well aware of the barriers their neighbors face. CCWV offers a vast array of services to more than 25,000 people each year. In responding to the needs of the community, CCWVa saw the recurring pattern of hospital readmissions firsthand and decided to do something about it.



The Intervention

In their efforts to be more proactive in helping to improve the health of West Virginians, CCWVa learned about an existing quasi-experimental LEO study on a similar program run by Catholic Charities Chicago (CCC) called the Community-Based Care transition Program (CCTP). The CCTP study showed that social worker-based hospital transition programs have the potential to reduce readmission rates by 20 percent. While this evidence on the impact of social worker-based hospital transition programs is very promising, the intervention has never been rigorously tested through a randomized controlled trial. 

Using the CCCprogram as a model, CCWVa launched their Hospital Transition Program (HTP) at three local partner hospitals. Integrated into the hospital setting, the social worker begins meeting with clients before they are discharged and continues to provide an intensive six-week follow-up including home visits. The social worker assesses the family and caregiver needs and works to address any obstacles that might inhibit or derail the client’s recovery. The support is based on the needs of the individual client and can include short-term tailored food pantry services, practical chronic disease management education and support, eligibility for emergency financial assistance, and supported connection to local resources for ongoing services as needed for health maintenance and stability.

Research Question

What is the effect of HTP on 30-day hospital readmission rates and costs of the costs associated with readmissions? How do these effects vary by patient acuity and insurance status?

Intended Outcomes

  • At the end of the six weeks, clients are in a place to maintain their health and safety at home at a higher level than they were able to before hospital admission, so that they have that stability for the long term.

Research Study Design

LEO is launching a randomized controlled trial (RCT) to evaluate the impact of HTP on readmission rates. The RCT is being evaluated in a high-risk setting as all three hospitals have high readmission rates. Referrals will be auto-generated through at each hospital based on high risk indicators for readmission—mostly low-income or high medical needs individuals from Medicaid and higher-risk elderly and disabled enrolled in Medicare. Patients will be ordered sequentially based on their admission to the hospital and when two new patients are added, one will be randomly assigned to a CCWVa case manager who will then contact the patient in the hospital, outline the services offered by HTP, and if they agree, consent the patient to receive services.

Based on the experiences of the current CCWVa case worker, we believe we should get about a 70 percent consent rate. That said, we are expanding the program considerably and using a different algorithm to select cases so to hedge our bets, we are planning on only a 50 percent consent rate at the start. CCWVa anticipates that each case manager can handle about 150 to 200 cases per year.  We expect that 2400 patients will be eligible across the three hospitals each year. Given an even  chance of being offered services,1200 will be offered services, 600 will consent to be treated if we observe a 50 percent consent rate.  If the 70 percent consent rate as reported by the current case manager materializes, this will still be within the outer bounds of what the case managers can handle. 

This research will provide important insights about how to provide care transitions and vulnerable populations—including the potential for clear policy implications. The Centers for Medicare and Medicaid Services (CMS) covers the cost for care transitions from a hospital to home; however, they currently only reimburse for these services if they are delivered by a medical provider such as a physician assistant, nurse practitioner, or a clinical nurse specialist. They do not reimburse if the transition is managed by a social worker. If the RCT is successful, it would suggest CMS should consider broadening reimbursement for care transitions.

LEO and CCWVa would like to recognize the three hospital partners that make this study possible: 

  • Cabell-Huntington Hospital, West Virginia
  • St. Mary's Medical Center, West Virginia
  • Wheeling Hospital, West Virginia


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