Transition to home: Rapid scaling of a multistate readmission prevention program for advanced alternative payment model participants

Reducing unnecessary readmissions to acute care hospitals is a key lever of success in many advanced alternative payment models. Despite the proven effectiveness of evidence-based transitional care, hospitals and health systems often have difficulty scaling and sustaining postdischarge transitional care programs. As the United States’ largest convener of Medicare’s Bundled Payments for Care Innovation Advanced (BPCI-A) program, Signify Health implemented and rapidly scaled a virtual-first, evidence-based, interdisciplinary transitional care program now serving patients in 15 states. In the first 12 months since its inception on February 1, 2021, the Transition to Home (TTH) program has coordinated care for more than 8,000 patients discharged from 68 hospitals participating in either BPCI-A or an ACO. By focusing on care plan review, facilitating access to home- and community-based services and supports, and reconnecting patients with their primary care and specialty providers, the TTH program has successfully reduced both 30- and 90-day rehospitalization rates. Early challenges included language barriers, documentation for proxy decision-making, and excessive precall preparation time.