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- Getting Started
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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 with discharge-related care than with any other aspect of care that the Centers for Medicare & Medicaid Services (CMS) measures1. Within 30 days of discharge, 19.6 % of Medicare beneficiaries are rehospitalized2, and the Medicare Payment Advisory Commission (MedPAC) estimates that up to 76 % of these readmissions may be preventable3. Rates of re-hospitalization, and health care utilization in general, vary substantially among individual hospitals and among geographic locations4,5. Therefore opportunities for improvement exist at both the individual provider level and in community-based strategies aimed at multiple providers and local/regional support infrastructure6,7.
Information contained within this toolkit is presented as a result of the 9th Statement of Work (SOW) Care Transitions Theme, where the goal was to improve transitional care for a population of fee-for-service Medicare beneficiaries living within a selected community. Success was measured by reductions in hospital readmission rates for the targeted population. Fourteen quality improvement organizations (QIOs) were contracted in the 9th SOW to reduce 30-day hospital readmission rates, improve rates of physician follow-up appointments within 30 days of discharge, improve HCAHPS scores for targeted hospitals, and to reduce the risk-standardized 30-day readmission rates for acute myocardial infarction, heart failure and pneumonia.
QIOs accomplished this work by engaging multiple providers (including hospitals, home health agencies, dialysis facilities, nursing homes, and physician offices), as well as patients, families, and community health care stakeholders in cooperative and synergistic quality improvement efforts. Each community implemented multiple interventions, with the QIO serving to assist in coordinating efforts, recruiting key participants into the work as needed, evaluating progress, synthesizing best practices, and creating a sustainable infrastructure so that the progress can continue after project completion.
The Theme was set up to allow QIOs maximum flexibility to develop and adapt local projects based on community strengths and local best practices, and to tailor solutions based on community priorities.
Care Transitions Literature
The repository document below is intended to act as an azimuth for locating information important to care transitions work – it does not provide access to materials that require registration or paid subscription. The document is organized into two sections: 1) ICPC NCC Articles, Resources, and Other Literature and 2) ICPC NCC Miscellaneous Resources. The first section houses journal articles, magazine articles, web articles and editorials, white papers, etc. while the second section houses resources such as tool kits, how-to guides, and websites that hyperlink to other such resources. Both sections are organized alphabetically by lead author in a fashion analogous to APA 6th edition. It should be noted that the web addresses are generally excluded from the citations in an effort to decrease NCC re-work when links become invalid and/or broken. There is however, enough information provided in each citation that a user could search the web and find the cited resource.
Visit the National Transitions of Care Coalition (NTOCC) website for more information on literature around Care Transitions through their Transitions of Care Compendium’ (TOC Compendium). The TOC Compendium is a collection of resources such as white papers, journal articles, and websites that a "Transitions of Care" professional or interested consumer might find useful in their practice or medical situation. Explore the TOC Compendium at: www.NTOCC.org/Compendium.
You can also use the Care Transitions Search Engine on the ICPC NCC website that is customized to look for high-quality content on improving care transitions and patient safety. 
Steps to Getting Started
Getting started on your efforts in care transitions may fo?low a series of steps, including identifying your overarching goals, recruiting and convening your partners, leadership, and community, conducting a root cause analysis within your community, implementing interventions, measuring results, and creating a sustainable approach to maintain gains.
As an organizer in this effort, you might start the planning process by asking yourself a few questions:
- Who are your people (who lives here, who works here, to whom is this important)?
- Who holds power in your community (hospitals, physician practice group, payers, other)?
- How far are you in your efforts to improve transitions of care?
- Do you have a motivating issue?
- Do you have pre-defined goals or results you aim to achieve?
- Do you have a mandate or a group to create a working, action-oriented team?
Some participants found that the most difficult thing to do is forge the will to make changes happen. Moving people to actually do something differently today, rather than following the familiar and dysfunctional patterns that have come to be accepted, can be challenging. You may have to consistently address the ongoing issue of generating and sustaining the will to drive improvement. 
We can learn from TED’s stance on developing leadership by watching the video, Derek Sivers: How to Start a Movement. It takes more than one person to create change, or in this case, a movement.
Consider addressing the following information to get started:
- Investigate data and the facts:
- The experiences and issues people are facing in your community’s systems is critical information.
- Consider looking into the costs and effectiveness of your community compared with other areas.
- Find a leader � effective leadership is essential:
- Someone (usually a group) should embody the vision, take risks, forge coalitions, exercise political pressure, and otherwise anchor the work.
Build on local issues:
- Something is probably already brewing � build on it! If many Medicare beneficiaries are bouncing back into hospitals after discharge, then consider: Can you generate interest that might move action over the issue?
- Think ahead:
- Always consider your timeframes and end goals, and keep the ideal structure of your community coalition in mind as you advance in your planning.
- Think globally and act locally:
- Adjust your structure, interventions, and measurements according to your community’s needs.
- Testing your ideas in small ways may help to get things started (once good ideas are proven to work, your commitment to implementation and expansion may be easier).
- Capture quality stories:
- Much about health and health care is a bit obscure to most people until it personally touches them, and stories are how people learn at both the cognitive and emotional levels.
If you are not a QIO, find out who your QIO is and reach out to them to begin discussing partnering opportunities.
The most important aspect may just be getting started. Bring people into the endeavor and build enthusiasm. Find a concept that you can easily implement and test it out in the most auspicious setting. Learn from the test and build your effort as time moves forward.
- Care Quality Information from the Consumer Perspective Hospital Survey (HCAHPS) Pilot
- Jencks SF, Williams MV, Coleman EA: Rehospitalizations among patients in the Medicare Fee-for-service Program. NEJM 2009 Apr 2; 360(14):1418-28.
- MedPAC: June 2007 Report to the Congress: Promoting Greater Efficiency in Medicare.
- Fisher E, Wennberg J, Stukel T, Sharp S: Hospital readmission rates for cohorts of Medicare beneficiaries in Boston and New Haven NEJM. 1994; 989-995.
- The Dartmouth Atlas of Healthcare, www.dartmouthatlas.org
- Kripalani S, Jackson AT, Schnipper JL, Coleman EA: Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. J Hosp Med 2008 Jul;3(4):349-52.
- Cumbler E, Carter J, Kutner J: Failure at the transition of care: challenges in the discharge of the vulnerable elderly patient. J Hosp Med 2007 Sep;2(5):314-23.