Welcome!
The Care Transitions Theme is a subnational theme that includes 14 QIOs. This theme focuses on improving coordination across the continuum of care. In particular, QIOs will promote seamless transitions from the hospital to home, skilled nursing care, or home health care. QIOs will work to reduce unnecessary readmissions to hospitals that may increase risk or harm to patients and cost to Medicare. CMS will look to QIOs to implement projects that effect process improvements to address issues in medication management, post-discharge follow-up, and plans of care for patients who move across health care settings.
Click on any of the dots in the map to the left to visit the website for that QIO.
The Care Transitions Learning Sessions are back in session! Check out the Learning Sessions page for upcoming calls and recordings of all of the past calls.
Care Transitions in the News
- CMS-Funded Care Transitions Health Care Quality Improvement Project Cuts Hospital Readmission Rate in Coached Population.
- Improving Outcomes Through Re-engineered Care Transitions: The New York Experience
- Aftercare Tips for Patients Checking Out of the Hospital: http://www.nytimes.com/2010/06/19/health/19patient.html?pagewanted=print
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Taking Care of Myself: A Guide for When I Leave the Hospital is a guide
for patients to help them care for themselves when they leave the
hospital. The easy-to-read guide can be used by both hospital staff and
patients during the discharge process and provides a way for patients to
track their medication schedules, upcoming medical appointments, and
important phone numbers.
http://www.ahrq.gov/qual/goinghomeguide.htm -
As part of The Care Transitions Project of Whatcom County (the Stepping
Stones Project), Qualis Health recruited and trained some Western
Washington University students to be transitions coaches for Medicare
patients being discharged from St. Joseph Hospital in Bellingham,
Washington. The experience was of value not only to the Medicare
recipients but proved to be a worthwhile educational experience for the
students. A recent article in Western Today, a Western Washington
University publication, highlights some of the students’ experiences.
http://onlinefast.org/wwutoday/spotlight/wwu-students-volunteer-coaches-stepping-stones-program - How to Avoid the Round-Trip Visit to the Hospital: Carolyn M. Clancy, M.D., Director of the Agency for Healthcare Research and Quality (AHRQ), offers brief, easy-to-understand advice columns for consumers to help navigate the health care system. In her latest column, Dr. Clancy highlights the steps patients and their family members/caregivers can take to prevent an unnecessary return trip to the hospital. To read Dr. Clancy's latest column, go to http://www.ahrq.gov/consumer/cc/cc060110.htm.
- Project Videos Provided by Qualis Health: "Going Home from the Hospital" and "Bridging Healthcare Gaps"
- "Health Tips for Older Adults"
-
Improving Care Transitions And Reducing Hospital Readmissions:
Establishing The Evidence For Community-Based Implementation Strategies Through The Care Transitions Theme -
VIDEOS: Hospital to Home
Medicare has two new videos to help caregivers and loved ones move from hospital to home smoothly:- Planning for Your Discharge outlines the questions you should ask and preparations you should make before your loved one leaves the hospital.
- Tips for Making a Hospital to Home Transition gives guidance on what to plan for once you’re back at home. It offers advice on talking with health care providers, preparing the home for new equipment needs, planning for additional expenses, and more.
- Watch both videos online at www.medicare.gov/caregivers/