Helping Hospitals Improve Care Transitions for Patients

In 2015, The Duke Endowment launched a two-year, $5 million grant program aimed at helping hospitals improve care transitions for patients and reduce avoidable readmissions.

Six hospitals in South Carolina and nine in North Carolina are part of the collaborative.


Health systems across the country are focusing on efforts to improve care transitions for patients being discharged from hospitals to community settings. Poor transitions – especially for frail older adults – can send patients back to the hospital, compromise health gains and add to costs.

In one study, the New England Journal of Medicine reported that nearly 20 percent of Medicare beneficiaries were readmitted within 30 days of a prior hospitalization. Further research showed that 76 percent of such readmissions could have been avoided. Hospital costs for those readmissions were estimated at more than $17 billion.

A federal program now incentivizes hospitals to examine organizational practices and find effective ways to reduce readmission rates. The Hospital Readmission Reduction Program, which levies penalties to acute care facilities with excessive rates, was established as part of the Affordable Care Act. The first round of penalties began in 2013.


At The Duke Endowment, several projects have focused on improving health outcomes for vulnerable patients and reducing unnecessary trips to the hospital. Trustees approved the first grants in this area in 2008.

In 2013, after reviewing previously-funded efforts, the Trustees of The Duke Endowment asked staff members to convene a diverse group of stakeholders to study the elements of a robust care transitions program.

The Board approved funding for a $5 million initiative in November 2015. Fifteen hospitals were selected to participate.

Over the two-year program, the hospitals will work together on implementing effective practices that enhance current care transitions efforts. Technical assistance teams, formed through the North Carolina and South Carolina hospital associations, are providing learning opportunities, coaching calls and site visits. As each hospital works to embed best practices into their procedures, a shared data portal will help track progress and compliance with evidence-based standards.

One key component of the program is an assessment tool that’s helping hospitals identify needs after discharge. Services for high-risk patients include a phone call within 24 hours, a home visit within three days and follow-up care with a physician within seven days.

The program is also helping hospitals implement and evaluate strategies to improve patient and family engagement. Engagement and motivation is critical in improving health outcomes and patient satisfaction, with research showing that more engaged patients have lower medical costs, fewer hospital admissions, and improved health behaviors.

Hospitals in the Endowment’s program are using the My Health Confidence Tool, designed to help practitioners start a conversation with patients and family members about prescribed treatment plans. Care Managers assess how confident patients are about receiving the support they need at home and engage them in planning for their ongoing care.

Participating Sites

North Carolina:

  • Appalachian Regional Healthcare System (Charles A. Cannon Jr. Memorial Hospital)
  • Blue Ridge HealthCare (Carolinas HealthCare System Blue Ridge)
  • FirstHealth of the Carolinas (FirstHealth Moore Regional Hospital)
  • Halifax Regional Medical Center
  • Iredell Memorial Hospital
  • Nash UNC Health Care
  • Novant Health Foundation Rowan Medical Center (Novant Health Rowan)
  • Sentara Albemarle Medical Center
  • Johnston UNC Health Care

South Carolina:

  • Baptist Easley Hospital
  • Beaufort Memorial Hospital
  • McLeod Loris Hospital
  • Self Regional Healthcare
  • Tidelands Health
  • Union Medical Center


Area of Work

  • Quality and safety of health care

Program Area

  • Health Care

Grantmaking Status

Areas of Work

  • Prevention and early intervention for at-risk children

    To equip children and families with skills to ensure that children reach developmental milestones to lead successful lives.

  • Out-of-home care for youth

    To drive child welfare systems toward greater accountability for child well-being.

  • Quality and safety of health care

    Improving the quality and safety of health care delivery

  • Access to health care

    Improving health by increasing access to comprehensive care

  • Prevention

    Expanding programs to promote health and prevent disease

  • Academic excellence

    Enhancing academic excellence through program and campus development

  • Educational access and success

    Increasing educational access and supporting a learning environment that promotes achievement

  • Campus and community engagement

    Promoting a culture of service, collaboration and engagement among schools and communities

  • Rural church development

    Building the infrastructure and capacity of United Methodist churches to enhance ministry and mission

  • Clergy leadership

    Strengthening United Methodist churches by improving the quality and effectiveness of church leadership

  • Congregational outreach

    Engaging United Methodist congregations in programs that serve their communities