The San Diego Care Transitions Partnership (SDCTP)

About the Program

Category: Health (Best in Category)

Year: 2015

The County of San Diego, Health and Human Services Agency Aging & Independence Services (AIS) in partnership with 13 hospitals formed a San Diego Care Transitions Partnership which has reduced readmission rates and healthcare costs. The partnership includes Scripps Health, Sharp HealthCare, Palomar Health, and the University of California San Diego (UCSD) Health System, consisting of11 hospitals with a total of 13 campuses. In late 2012, AIS received the largest award of funds in the country from the Community-based Care Transitions Program (CCTP) by the Centers for Medicare and Medicaid Services (CMS). The funding is used to provide comprehensive, patient-centered, hospital and community-based care transition services to high risk fee-for-service Medicare patients as they transition across care settings. In just two years, over 25,000 high risk Medicare patients received specialized care that included support from transitional care nurses, licensed pharmacists, healthcare coaches and social workers. The San Diego Care Transitions Partnership has successfully reduced the 30-day all cause readmission rate. The estimated readmission rate for patients who received CCTP services was 13.7%, 65.6% less than the SDCTP’s 2012 Target Group baseline of 39.8%. Between January 2013 and July 2014, the SDCTP prevented 667 readmissions. Since the average cost of a readmission in San Diego County is $12,922, conservatively, the overall Medicare savings in that timeframe was $3,224,695.