Showing Up for the Whole Person: A Transitional Care Management Program Reduces Readmissions

As part of its move to the value-based care model, which provides incentives for transitional care and lower readmissions, Michigan-based Corewell Health created a predictive model to identify patients at high risk of readmission and a transitional care management program to help those patients receive the services they need.  The program responds to the unique circumstances of each patient, including clinical health, behavioral health, and social determinants of health. It requires a multidisciplinary team of nurse care managers, social workers, and community health workers to “show up” for patients by removing as much of the administrative burden of follow-up care as possible. Patients who complete the program have a readmission rate of 7.8% compared to a baseline of 23% among all high-risk patients.

How They Did It

• Designed a predictive model to identify patients at high risk for readmission
• Created a program that addresses patients as whole people, with social, behavioral, and clinical needs
• Used Epic’s care coordination tool, Compass Rose, to help care managers prioritize upcoming tasks and review whole plans

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