As the results show, recognizing and supporting the
key roles that patients and their caregivers play in
improving care transitions appear to significantly
reduce the rates of rehospitalization, even in a heavily
penetrated Medicare Advantage market in which the
reduction of hospital use has been an explicit focus for
many years. The utilization findings were strongest at
30 and 90 days, suggesting that patients were able to
achieve a sustained benefit from the new skills and
tools they had learned while recovering from acute illness.
Furthermore, the transition coach and patient
developed a care plan that specifically addressed the
reason for the index hospitalization. Consequently,
rehospitalization for the condition that precipitated the
index hospitalization was significantly reduced at 90
and 180 days.