Coordination of Care

CJE SeniorLife

One-fifth of Medicare beneficiaries discharged from a hospital are readmitted within 30 days, and one-third are readmitted within 90 days.*

That statistic shows that too many high-risk elderly patients are being avoidably re-hospitalized after transitioning from hospital to home. To keep those patients healthy at home, Blue Cross and Blue Shield of Illinois is supporting CJE SeniorLife’s Transitional Care Program.

CJE’s Transitional Care Collaborative essentially picks up where each hospital’s discharge planning process leaves off – by following the patient home with a team of nurses and social workers to ensure that patients’ and families’ needs are met. This program provided up to five additional months of post-hospital care management, which included home visits, transportation for medical appointments, and other supports to ensure optimal aftercare.

In the first year of programming, CJE’s Transitional Care enjoyed impressive results. In addition to hiring a multi-lingual staff, which included nurses that speak Spanish, Russian, Polish, and Tagalog, program participant hospital readmission rate was 20 percent lower than baseline rates. Other notable outcomes:

≥85 percent of patients:

  • Understand post-discharge care instructions
  • Master self-care skills
  • Master medication regimen
  • Schedule and attend follow-up medical appointments

*2007 Medicare Report to Congress