Chicago Southland Coalition for Transition Care (CSCTC)
Last Revised: October 30, 2025
- Issue Areas
- Health and well-being
Program overview
Reducing hospital readmissions: Chicago Southland Coalition for Transition Care (CSCTC) is a Community-Based Care Transitions Program. It connects participants to social workers who help with their transition home and provide logistical assistance to patients following their hospital discharge. The program aims to reduce hospital readmission rates among Medicare patients.
Utilizing social workers: CSCTC was run by the Catholic Charities of the Archdiocese of Chicago between 2011 and 2015 as part of the national community-Based Care Transitions Program. It was implemented in four Chicago area hospitals serving 70 low income zip-codes. The program was staffed by social workers, a rarity for CCTPs, which typically utilized registered nurses or licensed practical nurses. All Medicare patients, regardless of the reason for their initial hospital admission, were eligible for the program after discharge.
Providing medical and logistical support: As part of CSCTC, patients were assigned a social worker, known as a transition coach. As part of CCTP programs these coaches typically met with patients throughout their recovery in the hospital, at their homes, or via phone, based on need. Social workers coordinated with patients to ensure they understood physicians’ medical instructions, had transportation to follow-up appointments, access to nutritional food and other necessities. Staff connected patients with community organizations and resources to aid their recovery. CSCTC included a meal delivery service and pharmacy support services offered in coordination with pharmacy chains.
- Strategies
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Navigating health care systems and services
- Cost per Participant
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$368 per patient (for the riskiest patients, save approximately $1,203 per patient).
A single study suggests that the Chicago Southland Coalition for Transition Care is a promising model for decreasing hospital readmission rates among Medicare patients.
A 2021 quasi experimental study found that CSCTC reduces 30, 60, and 90 day readmission rates by 14% relative to those of comparison hospitals. These results are statistically significant and the effects were driven by decreases in readmission among minority patients and individuals who were dual-eligible for Medicare and Medicaid.
Ensure coordination between hospitals and CCTP staff: A CCTP evaluation identified program staff integration into the hospital environment as a key factor in driving lower readmission rates. This can be done using the hospital-field worker staffing model in which some CCTP workers are stationed within the hospitals while others primarily perform field work. Integration may also be achieved by granting CCTV workers' hospital badges, in-hospital offices, and access to patient health records, when appropriate.
Secure a hospital champion: The same evaluation noted that identifying a high-level hospital staff member to act as a champion for the program helped to facilitate staff buy-in and overcome implementation barriers. Typically these individuals are leaders during the planning and execution process and have authority regarding quality improvement, discharge planning, and case management.
Include home visits: An evaluation of all CCTP programs found that participants who received at least one home visit had more positive outcomes relative to those who only received in-hospital visits. As such, local leaders interested in replicating this model should prioritize home visits as part of their model.
Utilize social workers: Many CCTPs utilized either exclusively medical professionals or some combination of social workers and nurses. By hiring only social workers, CSCTC was able to reduce the cost of the program without sacrificing lower readmission rates. In addition, social workers may be particularly well equipped to help patients overcome logistical and social barriers to recovery.