Alameda County Medical Center (ACMC) today announced it received a $690,926 grant from the Gordon and Betty Moore Foundation to implement a transitional care program aimed at reducing preventable readmission rates at its flagship Highland Hospital.

"The transition from hospital to home is a challenge for high risk patients who don't have adequate support after discharge," said Dr. Lyn Berry, Chief of Medical Staff for ACMC. "The Gordon and Betty Moore Foundation grant will enable us to place increased focus on the patients who need additional education, comprehensive assessment, and transition planning – all of which have been shown to reduce the incidence of preventable readmission. The grant will be implemented by a multidisciplinary team that has successfully piloted this project for the past year."

Based on an evidence-based model called Project RED, the transitional care program's goal is to reduce Highland's 30-day all cause preventable readmission rate for high risk patients by at least 30% according to Dr. Berry. The program also targets reduction to the 90-day all cause preventable readmission rate by at least 15% compared to 2010 baseline rates.

"Now we'll have some of the dedicated resources needed to give our high risk patients and their at-home caregivers enhanced teaching and coaching before discharge so they know what issues may arise and how to address them," said Dr. Berry. "Specific care plans, pre-scheduled follow-up appointments, and a secure handoff to their primary care providers will give patients with complex care needs some of the necessary support to avoid readmission following their hospital stay."

ACMC will use the grant to launch the transitional care program at Highland and to build additional resources to sustain these services over time.

Nationally, one-fifth of Medicare patients are readmitted to the hospital within 30 days of discharge and 34% are readmitted within 90 days. Researchers estimate that up to 90% of hospital readmissions within 30 days of discharge are unplanned. While Highland Hospital is below the national average for unplanned readmissions (in 2010, Highland had an 11.4% readmission rate for patients within 30 days and a 19.3% rate within 90 days), the hospital staff constantly works to improve excellence in patient care with a focus on improving outcomes and enhancing the continuity of care for all patients.

In addition to the toll unplanned admissions may take on a patient's health, they are costly: The annual national price tag to Medicare for unplanned hospital readmissions exceeds $17 billion. However, research has shown that it is possible to reduce readmission rates by providing patients with high quality and evidence-based care during hospitalization, at discharge, and in the immediate period after discharge.

Alameda County Medical Center ( is a nationally recognized public healthcare system with more than 2,800 employees, 500 physicians, and 475 accredited beds. ACMC provides comprehensive, high quality medical treatment and compassionate care to all residents of Alameda County. The integrated system of hospitals, clinics, and health services is staffed by healthcare professionals who are responsive to the diverse cultural needs of our community. ACMC fosters a learning environment with a wide range of educational programs and activities including medical research and education for students, interns and residents as well as continuing medical education for medical, nursing and other staff. ACMC operates six facilities: Highland Hospital in Oakland, John George Psychiatric Pavilion in San Leandro, Fairmont Hospital in San Leandro and three community-based wellness centers. The system provides a range of services from family and women's health to pediatrics, oncology and orthopedics.

The Gordon and Betty Moore Foundation, established in 2000, seeks to advance environmental conservation, scientific research, and patient care. The goal of the Betty Irene Moore Nursing Initiative, named after our co-founder, is to improve nursing-related patient outcomes of adult acute care hospitals in the San Francisco Bay Area and Greater Sacramento. For more information, please visit


Monique Binkley Smith

Alameda County Medical Center

(510) 437-4850

Genny Biggs

Gordon and Betty Moore Foundation

(650) 213-3021



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