The National Coordinating Center (NCC) for the Integrating Care for Populations and Communities Aim (ICPCA) assists Medicare Quality Improvement Organizations (QIOs) to promote seamless transitions between health care settings.
The ICPCA NCC Learning Sessions are back in session!
Check out the Learning Sessions page for upcoming calls and recordings of all of the past calls.
About the Aim
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.
How QIOs Are Making an Impact
Each QIO is providing technical assistance to communities within their states to implement improvement plans and interventions that coordinate hospital and community-based systems of care.
Communities 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.
For more information, please download the CMS Fact Sheet on the ICPC Aim.
How QIOs Measure Results
CMS will measure the rate of hospital readmissions, admissions, and cost savings in the identified 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.
For more information on the QIO program and other CMS strategic aims, please visit the CMS QIO page.