An innovative health care program launched in San Diego County to reduce hospital readmissions and improve health outcomes of patients with complex medical issues has been chosen by the Centers for Medicaid & Medicare Services (CMS) to expand services under the Affordable Care Act over the next two years.

The San Diego Care Transitions Partnership, which includes four of the region’s major health care systems and the County of San Diego Health and Human Services Agency (HHSA), will receive patient Medicare reimbursement over the next two years to implement the Community-based Care Transitions Program in 13 hospitals. The health care systems are Palomar Health, Scripps Health, Sharp HealthCare and the University of California, San Diego Health System.

“This partnership is a great example of how health care providers are working with the County to improve the health and well-being of residents,” said San Diego County Board of Supervisors Chairman Greg Cox. “I am proud that San Diego County has been recognized by the federal government for its commitment to innovation in health care.”

The Community-based Care Transitions Program will strive to serve approximately 21,000 medically complex Medicare patients, such as those with multiple chronic conditions, or patients who must follow complicated medication schedules. These patients will be linked with support services and programs that will teach specific skills for managing their own health. These skills include medication management, maintaining a personal health record and recognizing “red flags” in their health to know when to follow up with their doctor.

The goals of the program include reducing hospital readmissions for Medicare patients by 20%, and documenting measurable savings to the Medicare program. A 2009 pilot program involving 88 patients in San Diego County showed a reduction in hospital readmissions by more than half.

“One of the priorities outlined in the County’s Live Well, San Diego! initiative is working with our health care partners to build a better service delivery system,” said Nick Macchione, HHSA director. “I look forward to seeing this program fully implemented, and improving the quality of life for residents with complex medical issues while also reducing the costs for care.”

All participating hospitals are expected to implement the program by April 2013. After the initial project period, it may be extended annually for up to five years.

“This investment by CMS is an endorsement of the approach the regional health care systems and the county are taking to achieve a critical goal in health care – better health outcomes for patients and lower costs,” said Steven Escoboza, president of the Hospital Association of San Diego and Imperial Counties.