Welcome!
Integrating Care for Populations and Communities (ICPC) is a strategic Aim where Quality Improvement Organizations (QIOs) are bringing together hospitals, nursing homes, patient advocacy organizations, and other stakeholders in community coalitions. CMS will look to QIOs to implement community-based 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.
To learn more about the QIO program and the current work to lead rapid, large-scale change in health quality, please download the Overview Fact Sheet.
The Care Transitions Learning Sessions are currently underway! Check out the Learning Sessions page for upcoming calls and recordings of all of the past calls.
Care Transitions in the News
- The Community Based Care Transitions Program (CCTP) has announced the first and second set of partners for the program. Visit the CCTP webpage for more information and the Innovation Center webpage for the list of partners.
- The Care Transitions Intervention: Translating from Efficacy to Effectiveness. By Rachel Voss, MPH; Rebekah Gardner, MD; Rosa Baier, MPH; Kristen Butterfield, MPH; Susan Lehrman, MPH, PhD; Stefan Gravenstein, MD, MPH
- Understanding Care Transitions as a Patient Safety Issue from Patient Safety & Quality Healthcare, May/June 2011. By Sara Butterfield RN, BSN, CPHQ, CCM; Christine Stegel, RN, MS, CPHQ; Shelly Glock, LNHA, MBA; and Dennis Tartaglia, MA.
- All Aboard: Hospitalists should jump on transitions-of-care train now to help solve rehospitalization problems.
- Ramping Up For Higher Acuity; Nursing Facilities Respond to the Need for Reducing Hospitalizations.
Care Transitions in the Remington Report
- November/December 2011: Standardizing The Hospital Discharge Process For Patients With Heart Failure To Improve The Transition And Lower 30 Day Readmissions
- July/August 2011: A QIO-Renal Network Collaboration Experience: Addressing Care Transitions
- July/August 2011: Evaluation Of Medication Coaching To Reduce Hospital Re-Admissions In An Indiana Care Transitions Project
- July/August 2011: Mobilizing Community Volunteers To Improve Care Transitions: Lessons Learned From Stepping Stones
- May/June 2011: Improving Care Transitions and reducing Acute Care Hospitalizations. New Jersey Care Transitions Project Home Health Experience.
- May/June 2011: Stop & Watch Tool Reduces Avoidable Hospital Readmissions.
- March/April 2011: Transforming Transitions From Patient Interventions To Systems Change, Quality Partners Of Rhode Island’s Safe Transitions Project
- Jan/Feb 2011: CareTrek™: Reducing Readmissions Through Cross-Setting Work Groups
- Nov/Dec 2010: Connected For Health: A Community-Based Care Transitions Project, Colorado QIO
- Sept/Oct 2010: Sustaining Provider Engagement In Care Transitions: Community Collaborative Action, Florida QIO
- July/Aug 2010: CMS-Funded Care Transitions Health Care Quality Improvement Project Cuts Hospital Readmission Rate in Coached Population, Louisiana QIO
- May/June 2010: Improving Outcomes through Re-engineered Care Transitions- New York QIO
- Jan/Feb 2010: Improving Care Transitions And Reducing Hospital Readmissions: Establishing The Evidence For Community-Based Implementation Strategies Through The Care Transitions Theme