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Impact of a Scalable Care Transitions Program for Readmission Avoidance
Brent Hamar, DDS, MPH; Elizabeth Y. Rula, PhD; Aaron R. Wells, PhD; Carter Coberley, PhD; James E. Pope, MD; and Daniel Varga, MD
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Impact of a Scalable Care Transitions Program for Readmission Avoidance

Brent Hamar, DDS, MPH; Elizabeth Y. Rula, PhD; Aaron R. Wells, PhD; Carter Coberley, PhD; James E. Pope, MD; and Daniel Varga, MD
The 30-day readmission risk was reduced 25% by a collaborative program model employing discharge planning and telephonic follow-up for high-risk patients with CMS penalty diagnoses.
Implementation of the CTS program by THR succeeded in significantly reducing readmissions for enrolled patients diagnosed with COPD, HF, AMI, or pneumonia meeting the recognized need to improve care and associated outcomes among a growing number of higher-complexity cases. An innovative approach to improving patient support and care coordination, the CTS program is a collaborative model designed as a scalable and sustainable approach that maximizes efficient resource use while improving quality of care and continuity in the transition from hospital to home. The implications may extend beyond the evaluated diagnoses given that CTS is applicable to additional conditions that may be included within future expansion of the readmission avoidance directive. Overall, CTS is a viable option for institutions wishing to efficiently implement an effective approach to reducing avoidable readmissions. 

Author Affiliations: Center for Health Research, Healthways, Inc (BH, EYR, ARW, CC, JEP), Franklin, TN; Texas Health Resources (DV), Arlington, TX.

Source of Funding: The study was funded by Healthways, Inc.

Author Disclosures: Drs Hamar, Rula, Wells, Coberley, and Pope are employees and stockholders of Healthways, Inc, which is the vendor of the program evaluated in this manuscript.

Authorship Information: Concept and design (BH, EYR, ARW, CC, JEP, DV); acquisition of data (BH, EYR); analysis and interpretation of data (BH, EYR, ARW, JEP); drafting of the manuscript (BH, EYR); critical revision of the manuscript for important intellectual content (BH, EYR, ARW, CC, JEP, DV); statistical analysis (BH, ARW); administrative, technical, or logistic support (EYR, DV); and supervision (EYR, CC, JEP, DV).

Address correspondence to: Elizabeth Y. Rula, PhD, Healthways, Inc, 701 Cool Springs Blvd, Franklin, TN 37067. E-mail:
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