HIMSS Davies Award Case Study Transitions of Care 1 The Evolution of a Transitions of Care Program Jefferson Health Primary Contact Information: • Tina Sokolowski- Vice President Population Health Services • tina.sokowlowsi@jefferson.edu • 215-350-4724 Clinical Project Lead: • Laura Gontz- Director Care Coordination • laura.gontz@jefferson.edu • 267-671-7642 IT Project Lead: • Kyle Cibak – Director Actuarial Informatics • kyle.cibak@jefferson.edu • 215-955-1559 Executive Summary Since the passage of the Affordable Care Act in 2010, healthcare has undergone a paradigm shift from a volume-based fee-for-service to an outcomes-based payment model. For Jefferson Health and other providers employing a continuum of care model (a cohesive care system that guides

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