Care Transitions/
Reducing 30-Day Hospital Readmissions

Connecting for Health

The Centers for Medicare & Medicaid Services (CMS) Care Transitions initiative will improve care coordination and reduce hospital readmissions across settings of care.

HealthInsight works with providers, purchasers, payers, and consumers in Nevada and Utah in an effort to achieve the best possible outcome after a hospital discharge.

The goal of this project is part of a larger national goal known as ‘The Triple Aim’ which aims to improve the health of the American population, significantly improve the delivery of healthcare, and to dramatically reduce healthcare costs. This can be achieved through the reduction of unnecessary hospital readmissions, improvement in information transfer between providers, and with the increased engagement of patients in their own healthcare.

Areas of focus include:

• Comprehensive care coordination post hospital discharge, including follow up with one’s primary care physician
• Patient-centered care plans that embrace the physical and the social aspects of one’s health
• Medication management and reconciliation
• Improving communication between healthcare providers and caregivers

Webinar and Learning Opportunities

Preventing hospital readmissions is a community problem requiring community participation. HealthInsight offers periodic educational opportunties on various topics to assist in reducing preventable hospital readmissions. Click here to view HealthInsight's current events.

The Colorado Foundation for Medical Care (CFMC) is the Quality Improvement Organization (QIO) for Colorado, and offers educational opportunities for QIOs, providers, and partners. Click here to view the schedule on CFMC's website.

Patient and Provider Communication

Agency on Aging- HHS
6 Chapter toolkit which aims to help states and/or organizations prepare for care transitions and includes lessons learned from communities who received funding from the ADRC (Aging & Disability Resource Center) program.

BOOSTing Care Transitions Resource Room
This web page is supported by the Society of Hospital Medicine and contains materials related to the Project Boost Care Transitions Program. The primary audience is hospital based personnel.

Center for Health Transformation
The Center is a high impact collaboration of private and public sector leaders committed to creating a 21st century intelligent health systems that saves lives and money for all Americans.

eQHealth-Solutions
Louisiana’s Quality Improvement Organization (QIO)
11 page document describing using a Care Coordinator to decrease hospital readmissions. Highlights include identified benefits of this model for patients, physicians, and payors.

Health Care Leader Action Guide to Reduce Avoidable Readmissions
Reducing avoidable hospital readmissions is an opportunity to improve quality and reduce costs in the health care system. This guide is designed to serve as a starting point for hospital leaders to assess, prioritize, implement, and monitor strategies to reduce avoidable readmissions.

Improving Chronic Care
This is dedicated to the idea that U.S. healthcare can do better. Over 145 million people suffer from chronic conditions. Providers who care for chronically ill patients can be better supported with evidence-based guidelines, specialty expertise, and information systems. Overall healthcare costs can be lowered through better care delivery.

Medicaring
A website dedicated to “empowering safer & seamless care transitions” by the Center for Elder Care & Advanced Illness at Altarum Institute. Contents include blogs, videos, and resources.

National Transitions of Care Coalition
This web page is supported by the National Transitions of Care Coalition and contains a collection of resources such as white papers, journal articles, and websites that a "Transitions of Care" professional or interested consumer might find useful in their practice or medical situation.

Next Step in Care
Next Step in Care provides easy-to-use guides to help family caregivers and health care providers work closely together to plan and implement safe and smooth transitions for chronically or seriously ill patients.

Transitions are moves between care settings, for example, hospital to home or rehab facility, or the start or end of home care agency services. Because transitions are often rushed, miscommunication and errors can occur.

Next Step in Care materials emphasize careful planning, clear communication, and ongoing care coordination.

Taking Care of Myself: A Guide for When I Leave the Hospital
When you leave the hospital, there are a lot of things you need to do to take care of yourself. You need to see your doctor, take your medicines, exercise, eat healthy foods, and know whom to call with questions or problems. This guide helps you keep track of all the things you need to do.

Additional Resources

• Encouraging Patients and Family Caregivers to Assert a More Active Role During Care Hand-Offs: The Care Transitions Intervention^SM
• IHI “Move Your Dot™: Measuring, Evaluating and Reducing Hospital Mortality Rates (Part 1)Medicare QIO Program
• IHI “Transforming Care at the Bedside How-To Guide: Creating an Ideal Transition Home for Patients with Heart Failure
• Medicare Quality Improvement Organization (QIO) Program
• Project RED: Re-engineered Discharge
• The Care Transitions Program
• The Dartmouth Atlas of Health Care
• The Transitional Care Model