Bethesda Inc. Grant to Help Expand TriHealth Care Transitions Program to Every Patient

Navigators Improve Transition from Hospital to Home;  Lowers Rate of Unnecessary Readmissions 

Cincinnati, OH, November 18, 2012 -- With the assistance of a three-year grant from Bethesda Inc., TriHealth has announced an expansion of its Care Transitions Navigator program to every patient admitted to TriHealth's Good Samaritan or Bethesda North hospitals. 

TriHealth’s Care Transitions Navigator program uses a proprietary model to assess each patient and link them to health and service professionals who coordinate care following discharge.  The only exception will be for obstetrics, substance abuse rehabilitation and psychiatric patients. The program is one way TriHealth is working to lower readmission rates by improving patient care and experiences. 

Nationally, for example, as many as 20 percent of Medicare patients are readmitted to hospitals within a month of discharge, often to treat the same condition.

Grant to Accelerate Program

The $2.8 million, three-year grant from Bethesda Inc. accelerates the expansion of the existing TriHealth Navigator for Senior Services program to cover all hospitalized patients. The existing Senior Navigator program assists older adults and their families as well as patients experiencing congestive heart failure with accessing a full spectrum of medical and community resources.

 “We're creating a better standard of patient care in Greater Cincinnati,” said John R. Robinson, MD, Senior Vice President of Hospital Operations for TriHealth. “The Care Transitions Navigator program transforms how patients’ post-discharge needs are managed and improves patient health by involving more knowledgeable and experienced care managers.  This ultimately decreases costs by reducing unnecessary hospital readmissions and emergency department visits."

TriHealth is adding six specially trained staff, including Clinical Nurse Leaders at hospital locations, and building a virtual Care Transition Department with additional “Navigators” to implement the program. The Navigators include social workers and nurses who can connect insured and uninsured patients with needed services in TriHealth's integrated health system or the community at large.  

Unique Assessment Model Transforms Care Delivery

“The model produced excellent results when it was piloted," said Ellen Katz, co-chair of the Bethesda Inc. grants committee.  "This TriHealth-developed algorithm can better and more efficiently assess patient needs and Navigators will help ensure they are being met.  That’s a basic tenet of our goal to find transformational ways to improve the overall health of our community.”

The TriHealth Care Transitions Navigator program utilizes both a Readmission Risk Assessment and a proprietary intervention algorithm to determine which patients may be of high risk for readmission. The patient-centered assessment is not based on particular diseases but on the whole person. It categorizes patients based on 13 question areas and includes questions regarding a patient's mental state, social support, economic resources and knowledge of their specific condition. 

TriHealth Expands Transitions of Care

Through the program, TriHealth’s goal is to achieve a 10 percent reduction in unnecessary hospital readmissions and a 20 percent reduction in unnecessary emergency room visits within 30 days of hospital discharge.  

Based on each patient’s assessment, Navigators coordinate with social and home health agencies, and other health providers, including hospice, to gain the best level of post-hospitalization care. A Navigator then contacts patients within a few days after discharge to ensure that follow-up appointments are made and that transportation is arranged.  Home visits for counseling or social work are provided to those patients who would benefit from them.

Navigators also strive for a high level of patient satisfaction, consistent with the mission of TriHealth. 

Bethesda Inc. Grants Help Transform Patient Care

The grant to TriHealth is part of Bethesda Inc.’s initiative to transform health care delivery in the region. The grant cycle includes awards to both TriHealth programs and broader community initiatives. Applications are evaluated based on a project’s ability to deliver results that include: better care for individuals; better health, especially for groups of people with chronic diseases, and lower cost, with an emphasis on reducing unnecessary expenses. Bethesda Inc. anticipates announcing additional grants in the coming months. Additional information can be found at

About TriHealth

Bethesda and Good Samaritan Hospital joined to form TriHealth in 1995, bringing together two of Cincinnati’s finest health care organizations. Through three acute care hospitals and more than 80 locations, TriHealth provides a wide range of clinical, educational, preventive and social programs. TriHealth's non-hospital services include physician practice management, fitness centers and fitness center management, occupational health centers, home health and hospice care. More information can be found 

About Bethesda Inc.

Bethesda Inc. has been a leader in developing health-related programs and services since 1896. Today, it supports health care innovation, collaboration, education and research in Greater Cincinnati. It is one of two joint sponsors of TriHealth and the parent corporation of the Bethesda Foundation Inc., which cultivates philanthropic support for Bethesda North and Bethesda Butler County hospitals, Hospice of Cincinnati, and Fernside children’s grief center.  For more information, visit