kari west

The Care Transitions Improvement Coalition (CTIC) of Southeast Michigan was organized for the purpose of reducing the 30-day hospital all cause readmission rate by 20% over five years by supporting interventions implemented under the Affordable Care Act’s Section 3026 funding, thereby improving patient and family satisfaction with the health care experience. Through shared experiences, coordinated processes and communication of evidenced based interventions, the CTIC seeks to measure and improve care transitions. The Coalition voted to disband when CMS ended the funding for Care Transitions. Our program was successful in meeting our goal.

Manage a team of Community Health Workers that are hospital-based with the goal of empowering patients being discharged from hospitals to take actions aimed at reducing avoidable re-hospitalizations. Effectively focus the team on achieving individual and program performance goals. Continually train the team to effectively enroll patients, implement the agency’s care transitions model, properly document cases and coordinate resource referrals to proper agency staff. Develop and refine processes to maximize performance. Work with agency’s fiscal and information technology staff to insure data integrity and proper programmatic billing. Serve as the program’s hospital and community liaison; Collaborate with a variety of community-based network of partners. Represent agency at Greater Detroit Area Health Council.