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Hospital readmissions are costly, often preventable, and the focus of a great deal of attention by health plans and by the Centers for Medicare and Medicaid Services (CMS). .

LifePlans is reducing avoidable hospital readmissions through our community-based Care Transitions Program. Based on Dr. Eric Colemanís Care Transitions Model, our program is designed to enhance the health status of program participants through improved symptom management and functional recovery strategies.

LifePlansí program focuses on direct work with members on such issues as:

  • Medication reconciliation and self-management
  • Development of a 30-day health goal with specific questions for the PCP or specialist
  • Education and coaching relating to any red-flags or warning signs that may develop shortly after a discharge
  • Establishing the follow-up visit with the PCP or specialist

Care Transition coaching is accomplished through the rapid deployment of any one of our field clinicians to conduct an in-home visit with the member for assessment, coaching, and follow-up very quickly after initial discharge.

Following the home visit, LifePlans care coordinators or care managers within the health plan, build on the foundation provided by the in-home visit and conduct ongoing telephonic coaching and care transitions work.

The results speak for themselves:

  • Working with a large Special Needs Plan, the addition of a LifePlans Care Transitions home visit in conjunction with ongoing telephonic coaching led to a 25% decline in the 90 day hospital readmission rate compared to the rate for a control group.

  • Members reported high satisfaction with the content of the visit and greater confidence in their own ability to manage themselves without having to return to the hospital. For every $1 invested in the program, the estimated return on investment (ROI) was $7.8.

For information on how the LifePlans Care Transitions Program can help you more effectively manage members, and develop the infrastructure to assure greater responsiveness to member needs, please contact:

Marc Cohen
Chief Research and Development Officer