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About the Theme

Opportunities for Improving Care Transitions

The United States has a 19.6% rate of hospital readmissions within 30 days of discharge. The process by which patients move from hospitals to other care settings is increasingly problematic as hospitals shorten lengths of stay and as care becomes more fragmented. Medicare patients report greater dissatisfaction related to discharges than to any other aspect of care that CMS measures.

In general, rehospitalization rates and health care utilization vary substantially across geographic locations, suggesting opportunities for improvement in areas with higher observed rates. The Medicare Payment Advisory Commission estimates that up to 76% of readmissions within 30 days of discharge may be preventable.

Where QIOs Are Focusing

QIOs in 14 participating states are working to promote seamless transitions from the hospital to home, skilled nursing care or home health care. Their goal is to not only reduce hospital readmissions within 30 days of discharge but also to create a model for improving care transitions.

• Providence, RI
• Upper Capitol Region, NY
• Western PA
• Southwestern NJ
• Metro Atlanta East, GA
• Tuscaloosa, AL
• Evansville, IN
• Greater Lansing Area, MI
• Omaha, NE
• Baton Rouge, LA
• North West Denver, CO
• Harlingen, TX
• Whatcom County, WA
• Miami-Dade, FL

How QIOs Are Making an Impact

Each Care Transitions QIO has identified a target community within its state, is implementing improvement plans that coordinate hospital and community-based systems of care, and will closely monitor results.

QIOs are implementing three types of interventions:

• Hospital and community interventions to improve processes of care at a system level—interventions may include redesigning discharge protocols, adopting information technology
  solutions, or creating a new protocol for transferring hospital patients to skilled nursing facilities;
• Interventions that impact hospital readmission for specific diseases or conditions, such as acute myocardial infarction, congestive heart failure (CHF) and pneumonia—these may include, for example, CHF disease management programs or the Care Transitions Intervention (providing patients with a “transition coach” and education in self-management skills); and
• Interventions that address community-specific reasons for hospital readmission—interventions may include creating services, such as palliative care, that can decrease the readmission rate simply because patients previously had no alternative to hospitalization.

How QIOs Measure Results

CMS will measure the rate of hospital readmissions in the Care Transitions communities. CMS will also determine whether the strategies that each QIO takes have been used throughout the entire project and their degree of success in reducing rehospitalizations. To meet these goals, QIOs are leading many projects at the local level to improve care coordination and quality.