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Our First Award Winners

This is the first series of features of the 2013 Building Michigan’s Health Care Workforce Awards. Stay tuned during the next 4 weeks to see all of them

Care Coordination and Health Information Exchange

Capital Area Collaborative for Care Transitions, Inc.

East Lansing, Michigan

Reducing preventable hospital readmissions is a major goal in a broader effort in health care reform to reduce the unnecessary costs. The Capital Area Collaborative for Care Transitions, Inc was developed to achieve that goal in Ingham, Clinton, and Eaton counties.

The CACCT is composed of two hospitals, several long-term care facilities, and other health care provider organizations.

The organization enrolls Medicare patients older than 65 who have been admitted to a participating hospital, with a variety of complex conditions, and have been hospitalized twice in the last three months and who are currently hospitalized for more than 8 days.

Enrolled patients received an intervention where patients were assigned to a Bridge Care Coordinator who meets with the patients and works to reconcile medications, arrange transportation to appointments, and ensure the patient has access to meals.

In the first month of implementation, the program has completed more than 80 interventions and reduced readmissions by 2% from the baseline.



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