About the Aim

Opportunities for Improving Care Transitions

The United States has a 17.6% 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

Quality Improvement Organizations (QIOs) in every state and territory, united in a network administered by the Centers for Medicare & Medicaid Services (CMS), have the flexibility to respond to local needs. At the same time, they offer providers the opportunity to contribute to broader health quality goals, such as those set by the U.S. Department of Health & Human Services’ National Quality Strategy. Rather than limiting their role to technical assistance, they are convening statewide learning and action networks (LANs) that recognize everyone has knowledge that can contribute to better care. By participating in a LAN, health care providers can harness the power of a 24/7 community for addressing common challenges, connect with a peer facility for mentoring, and be the first to know about improvement breakthroughs–and how they can replicate them in their own facility or practice.

Communities that join the QIO Program’s initiative to integrate care for populations and communities will contribute to a three-year, 20% national reduction in readmissions within 30 days of hospital discharge. Participants can expect to benefit from membership in a local care transitions coalition comprised of hospitals, nursing homes, home health agencies, dialysis centers, hospices and palliative care facilities, senior advocates like area agencies on aging, and other local stakeholders. QIOs in every state and territory will convene these coalitions and provide technical support as they implement a comprehensive, fully integrated approach to reducing avoidable readmissions.

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 and admissions in the identified communities and statewide. QIOs will also help communities identify measurement strategies to assess intervention progress and effectiveness. 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.

*Medical Payment Advisory Commission (MedPAC) Report to the Congress Promoting Greater Efficiency in Medicare, June 2007