Purpose
To support development of a plan for fully implementing the Care Transitions Model with Health Plan of San Mateo patients hospitalized at San Mateo Medical Center. The immediate goal of the grant is to double patient participation in the Care Transitions Model, and the long-term goal is to reduce 30-day and 90-day readmission rates for Health Plan of San Mateo patients hospitalized at San Mateo Medical Center by at least 30%.