Cobble Hill Health Center Partners with Brooklyn Hospitals to Prevent Rehospitalizations of the Elderly

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The Brooklyn Care Transition Coalition (BCTC) will counsel, educate and give all the instructions the patient needs to remain at home.

We will be there to ensure, through education and oversight that the patients we care for, maximize their ability to stay in their home…which is where they want to be more than anything.

Through the Community-based Care Transitions Program (CCTP), Cobble Hill Health Center will serve as the lead Community Based Organization (CBO) in New York to provide transition services and assistance to Medicare fee-for-service beneficiaries across 26 zip codes throughout northern and central Brooklyn. Cobble Hill was selected by the Center for Medicare and Medicaid Innovation to collaborate with Interfaith Medical Center and The Brooklyn Hospital Center. Together, the organizations form The Brooklyn Care Transition Coalition (BCTC). With over 40 years of experience in caring for the frail elderly and disabled in Brooklyn, Cobble Hill Health Center will lead the care transitions program.

BCTC is supported by community organizations and will work to reduce hospital readmissions, which is the highest among patients, 76-80 years old. “Hospital readmission after discharge home has proved to be a major problem in Brooklyn,” says Tony Lewis, Cobble Hill’s Administrator and Senior Leader of the innovative project. “We felt it was time for us to partner with local hospitals with a high readmission rate to see if we could help patients while they were home so they didn’t keep bouncing back and forth.”

According to data provided by the hospitals participating in the initiative, most patients were readmitted from the home and most commonly had a diagnosis of congestive heart failure, heart attack, or pneumonia. With the right kind of support and education provided by a Cobble Hill “coach”, the chances of the patient prematurely being readmitted to acute care, will diminish. “Our job will be to counsel, teach and give all the instructions the patient needs, so they can remain at home,” explains Alla Imas, BCTC Project Director. “If someone is not taking the correct medication in the way it was prescribed, or they don’t follow up with a visit to their doctor or clinic, chances are they are going to have a setback. Our job is to make sure that doesn’t happen.”

Patients leaving the hospital would be scored according to their risk of readmission. For patients with a higher score, those with multiple chronic conditions, who take a bouquet of at-risk medications and who have had a previous admission or emergency room visit in the past year, there would be more comprehensive, hands-on intervention. This would include medication management, nutritional support, including home delivery of meals if needed, and coordination with community service organizations. Modified intervention for patients who are medically more stable and have caregiver support would require checking up with the patient by telephone. Thankfully, all data is electronically recorded and stored through an internet based software system.

“Many patients are simply overwhelmed with information that doesn’t always make sense to them,” says Mr. Lewis. “They either don’t understand what the doctor instructed them to do or not do or they don’t understand enough about their medical condition to be aware of warning signs. We will be there to ensure, through education and oversight that the patients we care for, maximize their ability to stay in their home… which is where they want to be more than anything.”

For more information on Cobble Hill Health Center, please visit

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Nini Rubin
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