Accelerating Best Practices in Peer Support Around the World

CMS innovation


Peer Supporters as Transition Coaches for Reducing Hospital Readmissions

Clayton Velicer, MPH

Starting in October 2012, the Affordable Care Act’s Hospital Readmissions Reduction Program began imposing financial penalties on hospitals with excess hospital readmissions for conditions such as acute myocardial infarction, heart failure, and pneumonia. Information on the measures and payment adjustment methodologies are available at the CMS website. Our previous blog discussed the potential role for community health workers and peer supporters in reducing hospital readmissions. In this blog, we’ll look at a care transition program that has successfully used peer supporters to coach patients after being discharged from the hospital.

The California Healthcare Foundation, a grant-making nonprofit based in Oakland, recently released an issue brief on two models being pilot tested for transitioning care from hospitals. One of these models, the Coleman Transitions of Care model, is a four-week process designed to empower and support patients to take a…

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