Care Transitions Initiative

Improving Transitions of Care

Nationally almost 20% of Medicare beneficiaries are readmitted to the hospital within 30 days of discharge. It is estimated that up to 76% of these re-hospitalizations may be preventable. Source: MedPAC:June 2007 Report To Congress: Promoting Greater Efficiency in Medicare.

Improving transitions of care, as patients move between healthcare settings or go home, has been identified as a key way to reduce re-hospitalizations. At the heart of the issue is absence of standardized communication and information transfer of critical patient information among healthcare settings. During a care transition it is essential that important information is shared among, and understood by, patients, caregivers and healthcare professionals to improve patient outcomes and reduce unnecessary hospital readmissions.

One of the opportunities to improve transitions involves streamlining communication and care coordination between each healthcare setting and physician involved in the care management of the chronic, co-morbid patient population. Coordination of post-acute follow-up care with primary care physicians within seven days of discharge, cross-setting medication reconciliation, and enhanced patient/caregiver self-management skills all support prevention of avoidable acute-care hospitalizations.

From August 2008 through July 2011, IPRO piloted a project focused on care transitions in five New York State counties: Rensselaer, Saratoga, Schenectady, Warren and Washington. At that time we were one of 14 Medicare Quality Improvement Organizations (QIOs) funded by the Centers for Medicare & Medicaid Services (CMS) to improve care transitions and reduce unnecessary re-hospitalizations in communities selected by each QIO. IPRO adopted a multi-faceted community-wide level approach that succeeded in reducing re-hospitalization by breaking down barriers between health care provider settings and promoting shared responsibility for patient wellness.

As part of this initiative, IPRO worked with Seton Home Health Care and Seton Health/St. Mary's Hospital in Troy, NY to implement a system-based approach to medication reconciliation that supported substantial reductions in hospital re-admissions. "A System-Based Medication Reconciliation Process," Home Healthcare Nurse, November, December 2011.

More information about the pilot project.

For this next phase of our work aimed at activating patients, engaging healthcare providers, and joining forces with community organizations to reduce unnecessary hospital readmissions, IPRO is convening community coalitions -- which include representatives of hospitals, skilled nursing facilities, home health agencies, physician practices, patient advocacy organizations and other key community stakeholders -- across New York State. These coalitions support seamless transitions of patients from the hospital to home, skilled nursing care, home health care or hospice through process improvements that address medication management, post-discharge follow-up, and patient care plans. Contact us to learn how you can participate in a community coalition.

Empowering Individuals

A continued point of emphasis in IPRO's work to improve care transitions is ensuring that Medicare beneficiaries have the information they need to educate themselves about their role in ensuring effective transitions of care and in self-managing their conditions. We conduct outreach, both directly to beneficiaries and through their healthcare providers, to see that they have access to these resources. For more information about resources for beneficiaries and families, visit the General Public section of our website.

More information for Healthcare Professionals

If you are a healthcare professional and are interested in learning more about the work we're doing to improve transitions of care in New York State, please visit our Healthcare Professionals section and explore IPRO's wide variety of Care Transitions tools and resources.