BayPath's Care Transitions program recently earned some well-deserved honors, as it was ranked fourth in nation out of 36 programs across the country.

That's down from a high of approximately 110 programs, as lower-performing programs have been eliminated. BayPath and its partners in the Central Mass MetroWest Transitions in Care Collaborative have never been in danger of that, as they have consistently been ranked among the top programs in the country, including their fourth-place showing in the most recent rankings released from 2015.

"The coaches have worked incredibly hard to support patients as they transition home from the hospital, and their work clearly shows," said CCTP Supervisor Gwen Blumberg. "They're an awesome group of people with a wide range of experience."

The Community Care Transitions Progra m was introduced as part of the Affordable Care Act and was designed to improve the care of Medicare beneficiaries at high risk for readmission to the hospital. Care transition coaches support patients by providing specific tools and teaching self-management skills to ensure the needs of the patient are met during transitions across settings, such as hospital to home.

Blumberg noted that the average patient at Marlborough Hospital is nearly nine times more likely to be readmitted to the hospital, than a high-risk patient enrolled in CCTP. Marlborough Hospital works exclusively with BayPath's CCTP coaches, while BayPath coaches also work with patients at MetroWest Medical Center's facilities in Framingham and Natick.

BayPath's Care Transitions team consists of Blumberg, who was a CCTP coach herself before being promoted to supervisor last March, CCTP coaches Barbara Fawcett, Maria Zuniga, Nancy Dumart, Nicole Desimone and Sandra De Souza, and administrative assistant Alisa Troncoso. Blumberg praised the work of each of her team members.

" Alisa regularly works with different departments to ensure communication about discharges as well as set up transportation," said Blumberg. "Barbara has worked closely with ECC (Elder Community Care) to put mental health services in place for patients struggling to manage both physical and mental health conditions. Maria and the Nutrition department collaborated to provide meals for a home-bound patient discharged home alone with no food.

"Nancy has had clients open up to her about their experience recovering from substance addiction, and helped bring awareness to safe self-management of pain medication. Nicole linked a patient to a pharmacy that delivers, since without access to test strips he was just guessing what amount of insulin he needed. Our newest coach, Sandra, has done amazing work reaching out to individuals in need both in Boston and Brazil, and we are so excited to have her join the team. These are just a few of the things that the coaches and everyone here at BayPath are doing each day to make a difference in our community!"

"This success could not have been achieved without the help and collaboration of every department here at BayPath," said Blumberg. "Nutrition has helped get meals out in less than 24 hours for a patient discharged home without food. Our patients have gotten long-term supports in place with the help and advice of PCA, AFC, homecare and SCO. I&R and our Options Counselors have routinely helped us brainstorm community resources available to patients who otherwise would have fallen through the gaps in care. Thank you to all who have helped to dramatically improve quality of life for patients in our community."

BayPath's nationally ranked Care Transitions team (l-r): Supervisor Gwen Blumberg, Nicole Desimone, Maria Zuniga, Alisa Troncoso, Barbara Fawcett and Sandra De Souza (not pictured: Nancy Dumart).

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