iTransitions Program

The National Priorities Partnership Compact Action Brief "Preventing Hospital Readmissions: A $25 Billion Opportunity" shows that...

Fragmentation within the healthcare system contributes to hospital readmissions. Patients may be readmitted due to:

  • Inadequate information and preparation for post-discharge care and self-care
  • Poor transmission of hospital records and discharge instructions to primary care clinicians who manage post-discharge recovery or to organizations which provide post-discharge care
  • Untimely and uncoordinated post-hospital care in their community
  • Preventable medical errors/complications during the first hospital stay

The highest rates of readmitted patients:

  • Have heart failure, chronic obstructive pulmonary disease (COPD), psychoses, intestinal problems
  • Have had various types of surgery interventions (cardiac, joint replacement, or bariatric procedures)
  • Take six or more medications
  • Have depression and/or poor cognitive function
  • Have been hospitalized in the previous six months
  • Are discharged on weekends and holidays



We are aligning to the goals of the RARE (Reducing Avoidable Readmissions Effectively) Campaign


  • Comprehensive discharge planning

  • Medication management

  • Patient and family engagement

  • Transition care support

  • Transition communications


  • iTransitions program Is a High-Intensity Care Management program for clients currently in the hospital or skilled nursing facility who need placement in a senior housing community.


    • Transitions Assessment with RN/ SW care manager
    • Client-centric plan of care
    • Placement in screened senior housing communities
    • Post-transition care management services - up to 30 days


    Transitions of care coordination:

    • Review of discharge instructions, medication reconciliation, schedule initial PCP follow-up visit, chronic disease management teaching
    • Arrange for DME, transportation, skilled home care, etc
    • Referral and information on community programs & services