Reducing Hospital-Acquired Conditions and Readmissions

Hallmark Health System, Inc., is participating in the Community-based Care Transitions Program (CCTP) as part of one of the regional teams awarded funding by the CMS Innovation Center. A five-year program created by the Affordable Care Act, CCTP provides a broad spectrum of interventions and services for elderly patients at high risk of hospital readmission, through a partnership between acute care hospitals and community-based organizations. The goal of this program is to reduce readmissions by 20 percent among patients identified as high risk and to reach a target enrollment of 250 participants per month.