The Eastern Virginia Care Transitions Partnership

An Evidence-Based Practice

Description

Bay Aging and four other Area Agencies on Aging (AAAs), four health systems, three managed care organizations (MCOs), and other health care and human service providers worked together to provide direct referral assistance, case management, benefits counseling, family caregiver support, and other non-clinical services such as meals and transportation to Virginia’s dually eligible Medicare and Medicaid beneficiaries.

Goal / Mission

Reduce hospital/nursing home readmissions and improve care for older adults.

Impact

Reduced 30-day readmission rate from 18.2 to 8.9 percent over the course of 2 years, resulting in estimated savings of more than $17 million through 1,804 avoided readmissions.

Results / Accomplishments

Between 2013 and 2015, Eastern Virginia Care Transitions Partnership (EVCTP) completed home visits for 25,656 Medicare patients discharged from partner hospitals. As a result, the EVCTP enrollee readmission rate for 2016 decreased to 9.1%. Additionally, the average readmission rate dropped from 25 to 5% as a result of program participation.

About this Promising Practice

Organization(s)
The Eastern Virginia Care Transitions Partnership
Primary Contact
5306 Old Virginia Street
P.O. Box 610
Urbanna, Virginia 23175
804-758-2386
https://www.evctp.org
Topics
Health / Older Adults
Health / Other Conditions
Organization(s)
The Eastern Virginia Care Transitions Partnership
Date of implementation
2013
Location
Urbanna, VA
For more details
https://www.chcs.org/media/EVCTP-Case-Study_101217...
Target Audience
Older Adults

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An Evidence-Based Practice meets the following HCI criteria:

  1. The program description includes at a minimum: the sponsoring organization, program goals, program implementation steps, and outcomes that have demonstrated program success in achieving the program goal in one or more localities.
  2. The results from an evaluation of the program include quantitative measures showing improvement in the outcome(s) of interest after the implementation of the program (i.e. increase in smoking cessation, not just the delivery of a smoking cessation program). The outcome measure(s) is/are compared at relevant time periods before and after the intervention or program implementation. Alternatively, the evaluation study compares the outcome(s) between an intervention group and an appropriate control group.
  3. The study is of peer-review quality and presents numbers in a scientific manner; measurements of precision and reliability are included (e.g. confidence intervals, standard errors), results from statistical tests show a significant difference or change in the outcome measure(s), and relevant point estimates and p-values are presented. Note: if the results from an evaluation of a program are presented in a scientific manner and the outcome measure is improved compared to the baseline measurement or the control group but the difference is not statistically significant, the practice is classified as effective and not evidence-based.