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Background  The Affordable Care Act of 2010 proposed maximum penalty equal to 1% of regular Medicare reimbursements which prompted change in how hospitals regard 30-day readmissions. While several hospital to home transitional care models demonstrated a reduction in readmissions and cost savings, programs adapted to population needs and existing resources was essential.    Methods  Focusing on process and outcomes evaluation, a retrospective analysis of a modified community based care transitions program was conducted.    Results  In addition to high levels of patient satisfaction with the care transitions program, participants’ confidence with self care was significantly improved. Further, the program evaluation demonstrated a 73% reduction in readmissions and an actual Medicare cost savings during the 9-month study period of $214,192, excluding the cost to administer the program.    Conclusions  While there are several transitional care programs in existence, a customized approach is desirable and often required as the most cost effective way to manage care transitions and employ evidence based policy making. This study established some of the pitfalls when implementing a community-based transitional care program and demonstrated encouraging outcomes.

Evaluation of a modified community based care transitions model to reduce costs and improve outcomes