For the past year, CICOA Aging & In-Home Solutions has worked with a Medicaid payer to reduce readmissions to the hospital for certain high risk CICOA clients. CICOA provides services and support to the elderly and people with disabilities in Indiana. It’s important that CICOA, whose clients often have unique and multiple challenges, help manage these patients so that they service their contract appropriately, help their patients utilize healthcare resources appropriately, and most importantly, service their clients to the highest level possible.


Because CICOA covers customers throughout Indiana, they need to know all the locations where their patients receive health care. When one of CICOA’s clients present to an emergency room, CICOA receives an ADT (admission, discharge, transfer) report. IHIE sends these reports automatically into their EMR, where an auto box pops up to alert CICOA that one of these clients has visited an emergency department.Two staff people monitor this activity and contact the patient directly to see what happened, if they need additional assistance, and to help them understand their follow-up care instructions.


Donata Barnes
Director, Health Care Collaboration
CICOA Aging & In-Home Solutions
Clinical setting: Population Health


  • Allows staff to follow up with patients within one day (or less) of them being discharged.
  • Provides comfort to clients, many of whom need special care and may not be able to effectively transition themselves out of inpatient visit.
  • Project serves as example of impactful way to manage healthcare expenses; could serve as model to commercial payers.


“I am really excited that we have these ADT alerts, which have helped us to have a strong impact on our clientele.”
“These ADT alerts provide great transitions of care. It can help us provide support if they need additional services, ensure they have made necessary follow-up appointments and are taking the right medication dosages.”