The Eastern Virginia Care Transitions Partnership
An Evidence-Based Practice
Description
Bay Aging and four other Area Agencies on Aging (AAAs), four health systems, three managed care organizations (MCOs), and other health care and human service providers worked together to provide direct referral assistance, case management, benefits counseling, family caregiver support, and other non-clinical services such as meals and transportation to Virginia’s dually eligible Medicare and Medicaid beneficiaries.
Goal / Mission
Reduce hospital/nursing home readmissions and improve care for older adults.
Impact
Reduced 30-day readmission rate from 18.2 to 8.9 percent over the course of 2 years, resulting in estimated savings of more than $17 million through 1,804 avoided readmissions.
Results / Accomplishments
Between 2013 and 2015, Eastern Virginia Care Transitions Partnership (EVCTP) completed home visits for 25,656 Medicare patients discharged from partner hospitals. As a result, the EVCTP enrollee readmission rate for 2016 decreased to 9.1%. Additionally, the average readmission rate dropped from 25 to 5% as a result of program participation.
About this Promising Practice
Organization(s)
The Eastern Virginia Care Transitions Partnership
Primary Contact
Topics
Health / Older Adults
Health / Other Conditions
Health / Other Conditions
Organization(s)
The Eastern Virginia Care Transitions Partnership
Date of implementation
2013
Location
Urbanna, VA
For more details
Target Audience
Older Adults