Care Transitions to Reduce 30-Day Readmissions

DSRIP Project Title: Care transitions intervention model to reduce 30-day hospital readmissions for chronic health conditions (Project 2.b.iv)

Alliance staff contact: Nora Baratto | 518.701.2198Project Resources-01


Manage patients’ discharge plans, coordinate care between providers and address unmet medical and social needs to help keep people out of the hospital once they are discharged. Promote the safe and timely transfer of patients from one level of care or setting to another.

Why does the community need this project?

When patients leave the hospital after an in-patient stay, they receive standard instructions (discharge plan) to help care for themselves; however, they do not always have the resources or education to successfully follow the instructions. Therefore, many patients are at risk of being readmitted to the hospital due to medication errors, infections, or other complications.

Project Goal

Decrease the number of times patients are re-admitted to the hospital within thirty days of being discharged.

Our Plan

  • Meet with patients before they leave the hospital to review discharge instructions.
  • Coordinate the transfer of care from the hospital to the primary care physician, home care agency or other care providers, ensuring all providers are fully informed on the patients’ history, condition and needs.
  • Enlist social service providers to ensure patients’ housing, transportation, nutrition and other needs are addressed to help the patient remain well.