New Transitional Care Program for Rural Colorado Hospitals Helps Reduce Readmissions Among Colorado's Most Vulnerable Patients

Transitional Care Program Tailored to Resources of Colorado Critical Access Hospitals

DENVER, Sept. 15, 2017 /PRNewswire-iReach/ -- A pilot health care project has helped six Critical Access Hospitals (CAHs) in rural Colorado reduce avoidable readmissions like their big-city hospital cousins – without big-city resources. The results of the two-year project, which ends on September 18, may have a national impact, as the Centers for Medicare & Medicaid Services (CMS) rolls out innovations to health care providers who serve the nation's most vulnerable patients. 

The program, called Coordinated-Transitional Care (C-TraC), was funded by CMS through the Telligen Quality Improvement Organization (QIO), the Colorado Rural Health Center and C-TraC developer Dr. Amy Kind, a geriatrician and researcher in the Division of Geriatrics and Gerontology, Department of Medicine at the University of Wisconsin School of Medicine and Public Health. The nurse-led program uses follow-up phone calls after hospital discharge to help patients understand their care and avoid being readmitted when possible, which differs from traditional transitional care programs that include home visits. Participating Colorado hospitals included Melissa Memorial Hospital in Holyoke; Prowers Medical Center in Lamar; Southeast Colorado Hospital District in Springfield; Rio Grande Hospital in Del Norte; Spanish Peaks Regional Health Center in Walsenburg; and Wray Hospital in Wray.

New Transitional Care Program for Rural Colorado Hospitals Helps Reduce Readmissions

Because C-TraC is telephone-based, fewer staff resources are needed to run the program. The Critical Access Hospitals included in the C-TraC pilot only house up to 25 inpatient beds. C-TraC is an evidence-based program designed to reduce avoidable readmissions by encouraging patients to keep their medical appointments after discharge, monitoring for "red flag" symptoms that signal patient decline and catching medication errors before they happen.

Kind's research shows that C-TraC patients in other states had one-third fewer readmissions to the hospital within 30 days of discharge than patients who did not participate in C-TraC. Among hospitals who participated in this pilot, an analysis of Medicare claims showed that 9.5% of patients who participated in C-TraC were readmitted within 30 days versus 14.3% of non-participating patients. Moreover, four of the six participating hospitals have chosen to continue C-TraC after the project ends.

Leadership at the two hospitals that will not continue C-TraC said they hope to revive the program if hospital resources improve. 

Nurses and CEOs who participated in the pilot indicated that results were promising for participating hospitals. Participants said C-TraC provided a community benefit previously unmet in rural areas of Colorado. Other important findings from five of the six hospitals included:

·         "Red flags" identified in 11% to 26% of follow-up calls

·         Medication discrepancies uncovered in 3% to 28% of follow-up calls

Statistics show that about one in five Medicare patients are readmitted within 30 days of a hospital stay. Older patients with cognitive impairment, multiple chronic illnesses and limited social ties are at increased risk for readmissions. The Telligen QIO works with CMS to help improve care for Medicare patients in Colorado and other states. The pilot program was designed to test if an evidence-based transitional care program could be successfully adapted to the resources of rural Critical Access Hospitals. Risks for readmission are magnified in rural areas of Colorado, with rapidly aging populations and distant health care facilities and other social supports.

"C-TraC was beneficial in dramatically improving the transitions of care for discharged patients at Melissa Memorial Hospital," said Trampas Hutches, CEO of Melissa Memorial Hospital in Holyoke, Colo. "The C-TraC program worked in a lot of ways; most importantly, it improved the health outcomes of our patients."

About Telligen
For more than 45 years, Telligen population health management solutions have improved the quality and cost-effectiveness of health care for consumers and providers. Telligen serves the health and well-being needs of employer, union and health plan clients, as well as commercial clients and government programs at the federal, state and local level. Visit to learn more. The QIO Program is a national health care quality improvement program lead by CMS that works to convene health care

New Transitional Care Program for Rural Colorado Hospitals Helps Reduce Readmissions

providers and patients to share knowledge, spread best practices and achieve improvements in patient care while decreasing health care costs for all Americans. To learn more about Telligen's work with the QIO Program, visit

About the Colorado Rural Health Center
The Colorado Rural Health Center (CRHC) is Colorado's nonprofit State Office of Rural Health. CRHC works with federal, state and local partners to offer services and resources to rural health care providers, facilities and communities. Our mission is to enhance health care services in the state by providing information, education, linkages, tools and energy toward addressing rural health issues. Our vision is to improve health care services available to rural communities to ensure that all rural Coloradoans have access to comprehensive, affordable, high-quality health care. Visit to learn more.

This material was prepared by Telligen, the Medicare Quality Innovation Network Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW-CO-SIP1-09/14/17-2324

Media Contact: Matt Enquist, Colorado Rural Health Center, 3039969698,

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SOURCE Colorado Rural Health Center

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