We’ll Be in Touch: A Strategy for Every Patient, for Every Transition of Care

Jefferson Health’s Center City division in Philadelphia has been iterating on its transitional care management processes for many years. Between 2018 and 2021, it reduced 30-day readmissions by 13%, which in turn reduced penalties for Medicare readmissions by more than $2 million in the same time frame. Its combined population health and value-based care method creates more patient-centered transitions of care because patients get the right level of support, with both their health conditions and the social factors affecting their lives taken into consideration.

How They Did It

• Used an algorithm to prioritize outreach to recently discharged patients with a medium or high risk of readmission (EHR Documentation/Tools)
• Sent patients at low risk for readmission a questionnaire in MyJeffersonHealth (MyChart) to confirm they have the post-discharge resources they need (MyChart/Patient-Facing EHR Tools)
• Connected patients with social needs to social workers or other community resources
• Enrolled patients in Care Companion to manage their conditions and prevent readmissions
• Used the Excess Days in Acute Care (EDAC) measure to monitor performance in transitions of care (Analytics)

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