Post-Acute Transitions

In-Home Health Services

Catholic Health Services announced that its Catholic Health Care Transitions Services, Inc. has been approved by the Centers for Medicare & Medicaid Services (CMS) as a Community–based Organization to provide care transition services aimed at reducing 30-day readmission rates to hospitals.

The Community-based Care Transitions Program, (CCTP) is targeted to high-risk Medicare beneficiaries to provide them with the added support after hospital discharge as they move to new care settings including skilled nursing facilities, assisted living facilities and their own homes. The program’s goals are to reduce hospital readmissions, test sustainable interventions for care transition services, maintain or improve quality of care, and document measurable savings to the Medicare program. In addition, our Post-Acute Transitions Services is available to hospital systems, private payers and Managed Care Organizations.

Interventions to reduce the rate of readmissions include Medication Management and Reconciliation, Coaching and providing tools on self-management of disease processes Transportation to Doctors appointments, nutritional support services Coordinating needed post-acute home and community-based services and improving the transition of beneficiaries from the inpatient hospital setting to other care settings based upon the patient’s needs.

“This will uniquely position Catholic Health Services to work directly with local participating hospitals on their patient discharge planning to help ensure that their patient’s transition to the next correct level of care is successful, avoiding readmission to the acute care hospital. This is quite an accomplishment for the team at CHS that worked on the project and reflects very well on the Archdiocesan post-acute care system of services” says Joseph Catania, CEO of Catholic Health Services.

The CHS Care Transitions Services is one of  34 current CCTP sites in the country and the only one in south Florida.

The PostAcute Transitions Services (PATS) is a special program designed to help patients manage their transitions from hospital to home, with the assistance of a specially trained health coach. The health coach will visit the patient in the hospital, once at home and follow up with a series of phone calls. During the health coach’s engagement with the patient, several areas are monitored closely, including red flags on the patient’s condition, medication self-management, communication and follow-up with a physician.

Among the goals of the program are to provide safe transitions from the hospital to the skilled nursing facility, rehabilitation hospitals, assisted living residence or the patient’s own home environment, necessary tools for better health management; increase compliance with physician orders after hospital discharge; improve coordination of care across the post-acute continuum and reduce hospital readmissions and visits to the emergency room.

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