Patient-centered Care Transitions


This was a multi-year engagement with South Carolina Lt. Governor’s Office on Aging (LGOA). A collaboration was assembled by LGOA to pursue patient centered care transitions to decrease hospital readmissions. The partners included state and county agencies, the University of South Carolina School of Medicine, NGOs, CBOs, health IT vendors, and two major health organizations. A CMS grant was identified which the team successfully pursued with MataiNet's help.

Our efforts demonstrated success in reducing readmissions and received a national innovation award.


LGOA engaged MataiNet to help generate a proposal for CMS grant for patient centered care transitions. The proposal led to an award, and MataiNet engagement was extended to act as technology innovation lead, including research of various solutions and refinement of our proposed concept into a final implementable form. Our role also included expanding SC’s ADRC, so that it could be leveraged in the patient centered model.

Outcomes and Innovations

  • Leveraged online resources to inform and advise patients to improve conformance and reduce mistakes during recovery at home
  • Generated a “care transitions kit” that could be printed from nurses’ stations or online by family or patient
  • Led implementation of “CarePoint” patient care portal which received National Innovation Award in 2012
  • Program evolved and spread statewide

Example Artifacts


Helped lead proposal team to concept definition. Generated text, graphic, and cost inputs representing approximately 75% of the proposal. Upon award, guided team to define specific systems, customizations, and protocols to fulfill the objectives for the care transitions study and measure outcomes. Also led the team to define/build ADRC sites for participating AAAs.


  • Project BOOST protocols
  • Various system interfaces
    • Allscripts
    • Visionlink
    • ProjectRED
    • DotNetNuke
    • ooVoo
  • MS Office Suite
  • .Net, Visual Basic