Care Transitions – Project 2.b.i.v


To provide a 30-day supported transition period after a hospitalization to ensure discharge directions are understood and implemented by the patients who are at a higher risk of readmission. Many factors impact a patient’s successful transition and can include health literacy, language issues, and lack of engagement with the community health care system as well as social determinants to health. These factors can be addressed by a Health Coach who will meet with the patient in the hospital and do a home visit along with three follow-up phone calls to assess and address any barriers during the post 30-day timeframe.

Care Compass Network’s Goals

  • To work with Medicaid members that are not eligible for Health Home or professional home care and provide them with a Health Coach to help prevent avoidable readmissions.
  • Incorporate a Health Coach to improve the transition from a hospital to the home.
  • To build confidence in the patient and their caregiver and to become comfortable with managing their care after a hospital discharge through the help of a Health Coach.

Who is Eligible to Participate in the Project?

Any inpatient Hospital unit or Community-based Organization who provide Health Coach services to Medicaid members.


Latest News & Updates

Important Notice – Quarterly Reporting due by October 25th – October 18, 2017

For Partners Contracted to do Project Work: With the first 6 months of DSRIP Year 3 complete, CCN must submit the patient engagement reporting data to the DSRIP Independent Assessor in order to earn performance dollars tied to speed and scale. If you have not submitted your date for April 1st – September 30th 2017, please submit your activity by October 25th. All speed and scale reports or any document (could include a screenshot, email, word document, excel file, etc) that includes PHI should be submitted via the sFTP site. For additional information on the sFTP site, please click here to view the CCN sFTP Guide.

Care Compass Network Supports Partner Organizations Through IT Funding Opportunities – August 24, 2017

Care Compass Network (CCN) can help support partner organizations through approved IT funding opportunities. Currently, programs are in place to assist partners with new implementations of EMR/EHR systems and to provide funding to accommodate […] Read More

Care Transitions Process Get Up and Running to Empower Patients – January 17, 2017

When Care Compass Network (CCN) conducted a community health assessment in 2014, one of the major issues to emerge was avoidable readmission. Too many Medicaid patients who are discharged from the hospital return within 30-days. Often they come back needing […] Read More.