Innovations in Patient-Centered Care

The Affordable Care Act identified the goal of reducing preventable hospital readmissions as an important national priority. Health insurance plans have been addressing the root causes of readmissions for many years, through patient-centered programs such as nurse advice lines, health coaching, disease management, and case management. These programs help patients quickly find high-quality medical care and social services in their communities so that they can avoid emergencies.

As hospital admission and readmission rates have climbed in recent years -- particularly in Medicare -- health plans have refined their existing patient-centered programs and added new ones.

Some of the latest and most successful programs to improve care and reduce preventable readmissions focus on: providing patients with a Medical Home; Transitional Care; Home-Based Care, and Emergency Room Follow-Up. To learn more, click on the links below.


Emergency Room Follow-Up
Home-Based Care
Medical Home
Transitional Care 


Please click on the links below to access the Podcasts with:


PodcastsGroup Health Cooperative 

PodcastsIndependent Health 

PodcastsKaiser Permanente 

Learn More

If you have questions regarding this series, please contact:

Ellen J. Bayer 
Executive Director, Special Projects 

Center for Policy and Research
America’s Health Insurance Plans
601 Pennsylvania Avenue, NW
South Building, Suite 500
Washington, DC 20004
Ph: 202.778.3275 

Access all of AHIP’s qualitative and quantitative research on hospital readmissions.

For assistance with accessing materials or using this Web page, please contact AHIP Customer Solutions at 877-291-2247, or e-mail