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 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
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The
Community Based Care Transitions Program (CCTP) has announced the first
sites selected.
Visit the CCTP webpage for more information. - 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.
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Medicare spreads savings from Denver program: A Denver pilot project
helps older patients stay out of hospitals and is expanded nationally.
http://www.denverpost.com/news/ci_16843482 -
"Grand Junction, Colorado: How A Community Drew On Its Values To Shape A Superior Health System" by Marsha Thorson, Jane Brock, Jason Mitchell, and Joanne Lynn. Health Affairs. 2010 29: 1678-1686.
- 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"
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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/
Care Transitions in the Remington Report
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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