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Plymouth Area Transitions Team (PATT)

  • Need: Prepare medically complex patients for care needs after hospital discharge.
  • Intervention: A program focused on hospital discharges and care transitions for patients located in three New Hampshire counties
  • Results: Decreased high-risk patient readmissions and establishment of continuous care coordination focus.


The Plymouth Area Transitions Team (PATT) was an effort of the Central New Hampshire Health Partnership (CNHHP), a consortium of local healthcare agencies modeled after the evidence-based Project BOOST, Care Transitions Intervention, and the Transitional Care Model (TCM). Originally created for quality improvement and cost containment, the focus client base included patients with complex care needs as they transitioned across varied healthcare delivery settings in the greater Plymouth region of New Hampshire; specifically, the counties of Belknap, Grafton, and Merrimack.

PATT addressed community-based needs identified for a growing and aging patient population with associated high rates of chronic disease and chronic disease-related hospital admissions. In addition, the team also addressed several social determinants of health, such as limited income, housing conditions, and lack of transportation resources.

A Transition Care Manager (TCM) works with high-risk patients and their families to identify and resolve care plan challenges or discrepancies in order to ensure that the right care and support is received at the right time. This involves connecting with the patient's primary care provider, conducting a home visit follow-up within 24-72 hours post-discharge if needed, and weekly telephone calls or visits during the 30-day time frame post-discharge. This program also fostered an interactive relationship with the patient, family, and healthcare agencies in order to decrease readmissions and increase positive patient outcomes.

Also designed to decrease hospital readmission rates, patient education and empowerment was another focus during the transition from the hospital inpatient setting to outpatient care. To meet program goals, the full-time TCM was based in Speare Memorial Hospital to improve interdisciplinary collaboration and health outcomes across transitions of care.

Quarterly meetings involving PATT stakeholders include community agency staff such as emergency responders, law enforcement officers, and local senior center staff. The goal for these meetings is to broaden the scope of care transitions work in the community, create a forum for information sharing, and plan community health improvement projects.

In addition to providing assistance to high-risk patients, PATT worked with patients' families to identify and resolve care plan challenges or discrepancies, working with patients, families, and other healthcare agencies. This interaction created a relationship focused on connections, especially connections with the patient's primary care provider. When needed, home visits within 24 to 72 hours post-discharge were completed, along with weekly telephone calls or other home visits during the 30-day post-discharge time frame.

PATT also collaborated with professionals associated with Ignite: Making Connections That Spark Change, another local area New Hampshire outreach program. Since Ignite focuses on care and self-management support for older patients with depression and a co-occurring chronic condition, this collaboration increases outreach and intervention for the PATT patients.

With a goal of creating a complete care transitions scope in the community, PATT stakeholders held quarterly meetings with community agency staff, such as emergency responders, law enforcement officers, and local senior center staff. This forum created a platform for information sharing and planning for other community health improvement projects.

This program received support from a 2012-2015 Federal Office of Rural Health Policy (FORHP) Rural Health Care Services Outreach grant and as of 2017, remains sustainable.

Services offered

  • Standardized assessments at admission to identify complex, high-risk patients in need of enhanced support post-discharge
  • Patient and caregiver education
  • Patient self-care education including medication management
  • Multidisciplinary involvement with discharge planning, education, and medication reconciliation
  • Timely information flow between care settings
  • Patient follow-up within 72 hours of discharge
  • Developing resources for discharge preparation
  • Measurement of patient quality and outcomes of care
  • Coordinated communication process with a local hospice medical director also identified Physicians Orders for Life-Sustaining Treatment (POLST)-eligible patients


  • Initial outcomes data demonstrated that hospital readmissions decreased from 9% to 6%
  • Identification of high-risk patients at the time of hospital admission triggered an earlier and more thorough look into clinical and social issues impacting post-discharge outcomes
  • Strengthened relationships between hospital and primary care personnel created improved care coordination across transitional agencies

For more project information, please see project summary in the Rural Health Care Services Outreach Grant Program Source Book.


Challenges faced by this program include:

  • Patient medication understanding and adherence
  • TCM recruitment, hiring, and retention
  • Medical staff awareness of TCM role
  • Organizational technology differences impacting information sharing and standardizing documentation
  • Care partners' accessibility to multiple medication changes at different care transition


In order to create a similar program, it is important to:

  • Review TCM role and required skill set in relationship to project goals
  • Maintain continuous, regular, and proactive communications between partnering agencies
  • Create a medication reconciliation process that applies across the transitions of care
  • Develop relationships between the hospital and the region's primary care providers
  • Create a shared patient information data base between organizations using formal agreements and contracts
  • Acknowledge written or electronic communications between organizations in care transitions only tells a portion of any transition story
  • Develop clear, meaningful, and measurable processes and outcome goals
  • Establish a regular system for goal monitoring and attainment

Contact Information

Sharon Beaty, CEO
Mid-State Health Center

Health conditions
Healthcare quality

States served
New Hampshire

Date added
September 14, 2015

Date updated or reviewed
December 20, 2017

Suggested citation: Rural Health Information Hub, 2017. Plymouth Area Transitions Team (PATT) [online]. Rural Health Information Hub. Available at: [Accessed 14 April 2021]

Please contact the models and innovations contact directly for the most complete and current information about this program. Summaries of models and innovations are provided by RHIhub for your convenience. The programs described are not endorsed by RHIhub or by the Federal Office of Rural Health Policy. Each rural community should consider whether a particular project or approach is a good match for their community’s needs and capacity. While it is sometimes possible to adapt program components to match your resources, keep in mind that changes to the program design may impact results.