Transitional Care Program for Medicaid Patients and Integrated Care Teams

DESCRIPTION (provided by applicant): Preventable hospital admissions and readmissions are indicators of health system fragmentation and are associated with suboptimal patient outcomes and avoidable costs of care. Readmissions often result from leaving discharged patients to their own devices, unable to follow instructions they didn't understand, and not taking medications or getting the necessary follow-up care. Effective care coordination and transitions from hospital to home can prevent many of the pooroutcomes that give rise to hospital readmissions and reduce the economic costs of healthcare. The proposed initiative will design and test an innovative, systematic approach to managing hospital discharges of Medicaid patients who are served by an Accountable Care Organization (ACO). Due to the prevalence, hospitalization rates and associated costs of type 2 diabetes and comorbidities, we will tailor the intervention to that population. Care Coordinators employed by the ACO will be trained to use a tr