Year of Publication



Public Health

Degree Name

Master of Public Health (M.P.H.)

Committee Chair

Sarah Wackerbarth, PhD

Committee Member

Richard C. Ingram, DrPH

Committee Member

Julia F. Costich,JD, PhD


Problem: Unsuccessful care transitions for Medicare beneficiaries have resulted in high health expenditures and a diminished quality of care as the 30-day hospital readmission rate has increased. This has prompted the Centers for Medicare and Medicaid Services to require hospitals with high readmission rates to pay penalties. As a result, the Community-based Care Transitions Program was established under Section 3026 of the Affordable Care Act to provide health organizations funding to utilize models of care transition to improve the care transition process. The purpose of this capstone project was to identify whether two community-based organization programs, the Kentucky Appalachian Transition Services and Bluegrass “TLC” Transitional Care Program, had accomplished the goals set forth by the national Community-based Care Transitions Program.

Methods: This capstone used a case study approach. The analysis was based on a triangulation of data collected during interviews with that of existing agency and government documents. Interview questions to assess whether the programs had achieved the goals set forth by the Community-based Care Transitions Program and the model of transitional care they were following were based on Avedis Donabedian’s three domains of quality (structure, process, and outcome) as a conceptual and analytic framework.

Results: The Bluegrass “TLC” Transitional Care Program has had success accomplishing some of the goals set forth by the Community-Based Care Transitions Program. By following the model established under the National Transitions of Care Coalition, 50 percent lower readmission rates were found among high-risk participants enrolled in the program at Baptist Health Lexington compared to those who were qualified for the program but chose not to enroll. Kentucky Appalachian Transition Services utilization of the Coleman Care Transitions Program 5 and the Transitional Care Model has led Medicare beneficiaries enrolled in the program to receive quality care and successful accomplishment of many of the goals set forth by the Community-based Care Transitions Program. Kentucky Appalachian Transition Services reduced the 30-day, all-cause readmission rate for Medicare beneficiaries by an average of 12.3 percent across the four hospitals they collaborated with; the readmission rate is now approximately 19 percent.

Conclusion: Interviews conducted with stakeholders at the community-based organizations provided insight into the extensive development, implementation, and evaluation process of care transition programs and the positive impact they can have on hospital readmissions in years to come. However, the sustainability and development of new transition programs will depend on the recruitment of other payers. The utilization of Avedis Donabedian’s three domains of quality would be a beneficial model for future transition programs to utilize in order to evaluate the progress of their program in accomplishing its goals.

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