According to the Centers for Medicare and Medicaid services, nearly 1 in 5 Medicare patients who is discharged from the hospital is back at the hospital within 30 days.

The Community Based Care Transitions Program, created through the Affordable Care Act, is targeting those readmissions.

It’s at work in over 100 community-based organizations across the country, including the York County Area Agency on Aging.

Care Transitions participants, like patient Elizabeth Eisenbeil, are paired with a coach who’s job is to empower the patient to take control of their health.

Eisenbeil says: 

“If I didn’t have this program, I would have felt a little bit lonely, not having the support. And, I’m thankful.”

Watch the video to see how they work together to make her transition home a success:

Check out an interactive map to see where healthcare innovation, like the Community Based Care Transitions Program, are happening in Pennsylvania.