SENIOR TRANSITIONS OF CARE: Healthfirst helps to reduce hospital readmission for older adults

The Challenge: Older adults face significant readmission risk following hospital discharge, especially if they have been diagnosed with multiple chronic conditions and/or present unmet social needs, such as food insecurity and social isolation.

Our Goal: To better support members over age 55, reduce readmissions, and improve member health and wellness.

The Healthfirst Solution: ​​Through the JASA care transitions program, we targeted Healthfirst members over age 55 across five underserved ZIP codes in Brooklyn and Queens. Members were engaged as soon as possible after discharge and received help with managing medications, coordinating post-discharge care, as well as meeting socio-economic and behavioral health needs for 30 days.

Population Health Improvements: Members enrolled in JASA’s care transitions program were more likely to have two or more visits with their primary care physician (62.3% vs. 54.1%) and were much less likely to be non-accessing of PCP care (1.6% vs. 9.8%), compared to matched controls in the study.

Takeaway: The JASA care transitions program has shown that engaging with members after discharge helps improve the likelihood of primary care follow up.

This program was seeded by grant funding from the Samuels Foundation, and our results led to a contract renewal.