Transition to Home: Rapid Scaling of a Multistate Readmission Prevention Program for Advanced Alternative Payment Model Participants

Marc Rothman
Theresa Bretz
Angela Farinella
Justin Rock
John Kliewer
Lisa Brian
Brenda Tsai Meu Chong
Case Example
June 2022


A "virtual-first" transitional care program with an interdisciplinary care team can support reduced readmissions.


While many transitional care programs have been shown to reduce readmissions and improve patient outcomes, health systems may struggle to implement and sustain in-person transitional care programs due to a lack of cost-effectiveness and poor outcomes. Signify Health developed Transition to Home (TTH), a virtual-first, 90-day transitional care program for hospitals and physician practices in Medicare’s Bundled Payments for Care Innovation Advanced program. This telephonic program uses evidence-based transitional care assessments and interventions and stratifies patients based on their bundle designations as well as patient risk factors to match them with appropriate care. This case study compared rehospitalization outcomes of participants in TTH with those who declined to participate or did not respond to a phone call about the program.


The 90-day readmission rate for TTH participants was 12 percent lower than the historical benchmark, while the rate for non-TTH participants was unchanged. The results showed that the TTH intervention was effective for populations discharged to different settings, including home health and inpatient rehabilitation facilities. These findings may be impacted by selection bias between those who participated in the program and those that did not.


Transitional care interventions can address the substantial costs of readmissions for providers in bundled payment models. This case study illustrates the principles and high-level workflows for implementation of a telephonic transitional care intervention, which may be especially relevant for organizations in alternative payment models exploring cost-effective interventions.

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