The Challenge

The demand for specialized medical care by patients facing a serious illness has increased rapidly in the U.S. More than 90 million Americans live with at least one chronic illness, and seven out of ten Americans die from chronic disease. These numbers are projected to increase so that by 2020, 157 million Americans will have more than one chronic disease. Among the Medicare population, the toll is even greater: about nine out of ten deaths are associated with just nine chronic diseases, including congestive heart failure, chronic lung disease, cancer, coronary artery disease, renal failure, peripheral vascular disease, diabetes, chronic liver disease and dementia. As chronic disease progresses, the amount of care delivered and costs associated with this care increases dramatically. A mere 5% of Medicare patients in their last year of life account for about 50% of Medicare’s total yearly spending, largely due to hospitalizations from chronic illness. Equally notable, much of this care is not even aligned with patient and family goals.

Studies continue to show that our current “default pathway” of over treatment in a patient’s final year not only fails to prolong life but actually worsens their quality of life. Our fragmented health care system is unable to meet the needs of these patients leaving them and their families to suffer unnecessarily from preventable and treatable sources. This has clear implications for payers and results in higher payer expenditures without improvement in the quality of care or the patient experience.

Chronic disease management is one of the few areas in healthcare where patients, caregivers, physicians and health plans’ incentives are well aligned.


Care redesign of chronic disease management is essential to the delivery of high-quality care and favorable financial value-based care. Controlled studies have shown that outpatient palliative care programs have the ability to decrease overall medical costs by 30% to 40% primarily by reducing unnecessary and preventable ER visits, hospital admissions, and skilled nursing facility and rehab admissions. Care coordination with prompt identification and management of symptoms of distress is central to improving quality of care and preventing overutilization of the health care system. Transitions Health Partners is a physician-owned local company comprised of Transitions Home Health Care (Medicare A certified) and Transitions Chronic Care (Medicare B home-based palliative care company). Our unique approach promotes well-coordinated care by emphasizing early symptom management as patients move across care settings and are discharged home.

Led by a board certified palliative care physician, the Transitions Health Partners team assists in the management of complex care needs as the patient transitions from acute care to home-based settings. The Transitions Chronic Care nurse practitioners are board-certified, hospital credentialed, and work intimately with the hospital discharge teams and the post-acute facilities. They conduct periodic visits as Palliative specialists in the various facilities to assure continuity of care and a smooth transition back to home, and then conduct medical house-calls as needed to reduce the risk of readmission. The Transitions Home Health Care clinicians provide quality home health care and are trained to recognize symptoms of distress before they become severe.

It is often difficult for a patient to see a PCP or specialist when a patient is chronically ill or recovering from hospitalization.

Unlike some resources — whose default response is generally to send a symptomatic patient to the ER— the Transitions Home Health Care clinicians communicate early signs and symptoms of distress directly to our Transitions Chronic Care nurse practitioners or medical director. The NP or physician then evaluates and addresses the situation before it becomes an emergency, and facilitates contact with the PCP or the specialist as needed.

Modified to meet the needs of specific health plans, Transitions services include:

  • Accountability through a patient’s episode of care or for the duration of a patient’s chronic disease.
  • In addition to traditional home health services, the use of a unique team-based approach that gives each patient access to his or her own care team that includes a board certified Hospice/ Palliative Care physician, a board certified nurse practitioner, clinical social worker and a medical assistant.
  • A patient/family centered approach that includes shared decision making and goal-setting with both the patient and family. This approach encompasses all aspects of care by examining physical, psychological, emotional, cultural and spiritual factors and preferences.
  • Coordination of care and communication with the PCP and specialists as the patient transfers from the acute care setting to another facility and eventually home.
  • Highly predictable and usable Hospitalization Risk Assessment Tool.
  • Emphasis on HCC coding education of our nurse practitioners.
  • 24/7 support to patients and their families with short term medical house calls as indicated.


Transitions has partnered with Centura Health Avista Adventist Hospital since 2013. In 2014, we were consulted on 76 patients with high-risk readmit scores. Of the 76 patients seen by Transitions, we had only 3 patients readmitted within a 30-day period. Avista was the only hospital in all of Centura’s 17 hospitals that did not get fined for readmits in 2014. We maintained this readmit rate for our patients in 2015 and 2016.

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Transitions Home Health Care