Description

This report is a case study of the Eastern Virginia Care Transitions Partnerships. The partnership in southeastern Virginia was designed to reduce hospital readmissions and improve quality of care among older adults and those with complex illness through an evidence-based care transition model and in-home assessments. This unique collaborative effort was a large-scale partnership including Bay Aging and four other Area Agencies on Aging (AAAs), four health systems, three managed care organizations (MCOs), and other health care and human service providers. The partnership reduced 30-day readmission rate for older adults from 18.2% to 8.9% over two years, with an estimated savings of over $17 million.