Supporting Providers in Improving Transitional Care
Older patients with chronic illness often require care from a variety
of practitioners in multiple settings, including hospitals, nursing
homes, home care services, and physician offices. Despite the focus on
process quality and measurable improvements in disease-specific care
within each of these settings in recent years, each setting remains
professionally isolated from the others, creating a unique quality gap.
The purpose of this project is to develop an improvement framework for
transitions across settings to reduce 14-day and 30-day readmissions
after hospital discharge.
The Colorado Foundation for Medical Care (CFMC), the Medicare quality improvement organization for Colorado, prepared this material under
contract with the Centers for Medicare & Medicaid Services (CMS), an
agency of the U.S. Department of Health and Human Services. The contents
do not necessarily reflect CMS Policy.
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