Care Transitions Program

Citation: Gardner, R., Li, Q., Baier, R., Butterfield, K., Coleman, E., & Gravenstein, S. (2014). Is Implementation of the Care Transitions Intervention Associated with Cost Avoidance After Hospital Discharge? Journal of General Internal Medicine, 29(6), 878–884.


Poorly-executed transitions out of the hospital contribute significant costs to the healthcare system. Several evidence-based interventions can reduce post-discharge utilization.


To evaluate the cost avoidance associated with implementation of the Care Transitions Intervention (CTI).


A quasi-experimental cohort study using consecutive convenience sampling.


Fee-for-service Medicare beneficiaries hospitalized from 1 January 2009 to 31 May 2011 in six Rhode Island hospitals.


The CTI is a patient-centered coaching intervention to empower individuals to better manage their health. It begins in-hospital and continues for 30 days, including one home visit and one to two phone calls.

Main Measures

We examined post-discharge total utilization and costs for patients who received coaching (intervention group), who declined or were lost to follow-up (internal control group), and who were eligible, but not approached (external control group), using propensity score matching to control for baseline differences.

Key Results

Compared to matched internal controls (N = 321), the intervention group had significantly lower utilization in the 6 months after discharge and lower mean total health care costs ($14,729 vs. $18,779, P = 0.03). The cost avoided per patient receiving the intervention was $3,752, compared to internal controls. Results for the external control group were similar. Shifting of costs to other utilization types was not observed.


This analysis demonstrates that the CTI generates meaningful cost avoidance for at least 6 months post-hospitalization, and also provides useful metrics to evaluate the impact and cost avoidance of hospital readmission reduction programs.