CHA and Community Partners Among Nation's Top Performers in Pilot to Reduce Hospital Readmission Rates


Cambridge, Mass. — Cambridge Health Alliance (CHA), in collaboration with Somerville Cambridge Elder Services, Mystic Valley Elder Services, and Hallmark Health, is among the top performers in an innovative national pilot program to reduce hospital readmission rates.

The group is one of 72 community-based programs across the US participating in the Centers for Medicare & Medicaid Services (CMS) Community Care Transitions Project (CCTP). According to CMS findings, the CHA group reduced 30-day readmission rates in a group of high-risk patients by nearly nine percent over a two-year period, ranking among the best improvements nationally.

The CCTP aims to improve transitions from the hospital to other care settings to enhance quality of care, reduce re-admissions for high-risk patients, and show measurable savings to the Medicare program. This is accomplished, in part, by giving patients appropriate support and services after their hospital stay.

According to CMS, “nearly one in five Medicare patients discharged from a hospital are readmitted within 30 days, at a cost of over $26 billion every year.” So identifying the key drivers of hospital re-admissions and developing interventions to help patients stay healthier after discharge are important to older adults and to the nation.

The CHA component of the project, known as the Hospital-to-Home Program, includes both CHA’s Cambridge and Whidden Hospitals. At both hospitals, transition facilitators meet with patients before discharge to learn about their health care needs and assess their home care requirements. This is followed up with home visits from a transition facilitator or a nurse practitioner within 48 hours of discharge. Ongoing phone calls allow the team to further monitor patients’ health.

“We have learned that providing excellent health care necessitates supporting our patients in their homes and community,” said Rich Balaban, MD, medical director of CHA’s Hospital-to-Home Program. “Our partners have enabled us to extend our reach so that together, we now provide a broad range of community-based medical and home care services. We are proud of the progress we have made and the many lives we have improved.”