CMSHealthDisparitie

The Care Transitions Theme is a sub-national Theme that includes 14 QIOs. This Theme focuses on improving coordination across the continuum of care. In particular, QIOs will promote seamless transitions from the hospital to home, skilled nursing care, or home health care for all beneficiaries. QIOs will work to reduce unnecessary re-admissions to hospitals that may increase risk or harm to patients and/or cost to the Medicare Program.  The Centers for Medicare & Medicaid Services (CMS) will expect QIOs to implement projects that affect process improvements to address issues in medication management, post-discharge follow-up, and plans-of-care for patients who move across health care settings.

Alabama (The Alabama Quality Assurance Foundation (AQAF)  - The Post Acute Transitions in Healthcare (PATH) Alabama project plan is a portfolio of aligned projects capable of achieving the aim of reducing readmissions of Medicare beneficiaries. The PATH Alabama multi-modal plan is focused on redesigning processes across organizational boundaries, promoting evidence-based care delivery, specific to the various targeted levels of care, and empowering the beneficiary in self-management strategies.

Colorado - The Colorado Foundation for Medical Care’s (CFMC) project is focused on engaging a community of providers, community organizations, patients and caregivers in a steering committee to ensure sustainability for the future of this project, as well as, to significantly decrease community re-hospitalizations.  Building the community steering committee has been the first step in ensuring the success of the work-plan. 

Florida – Florida Medical Quality Assurance, Inc. (FMQAI) will partner with organizations to promote patient safety through improved care coordination between healthcare providers within a target population of Miami Dade County.  FMQAI activities will focus on: Patient Centered Record, Historia Clinica Personal, Physician Follow-Up, Medication Self-Management and Disease Self-Management.

Georgia – Georgia Medical Care Foundation (GMCF) will champion community-care transition interventions to measurably improve post-acute care coordination and reduce re-hospitalization rates within a targeted Georgia community. The interventions may depend on changes in processes of care that engage more than one provider (including hospitals, home-health agencies, nursing homes, dialysis centers, and physician offices), as well as, patients, families and stakeholders.

Indiana – Health Care Excel (HCE)  will design customized management solutions and develop appropriate educational programs to significantly improve the delivery of health services and improve quality and safety during patient hand-offs. 

Louisiana – The Louisiana Health Care Review’s (LHCR) project is focused on transition coaching interventions targeted to the diagnosis of pneumonia, with one unit at the local hospital.  They are developing Medicare beneficiary tools to include a Personal Health Record, a discharge checklist, a coaching consent form, and a red-flag checklist. 

Michigan – MPRO, Medicare Quality Assurance Organization for Michigan, will work with community stakeholders identified as having potential programs that can interface with this project. MPRO will conduct individual site visits and phone contact in the targeted community provider settings.

Nebraska – CIMRO Quality Healthcare Solutions,  of Nebraska's local project, CareTrek, is bringing together appropriate healthcare providers, stakeholders and community organizations to develop and implement an evolving intervention plan to reduce re-hospitalization among Medicare beneficiaries residing within Douglas and Sarpy counties by addressing patient medication management, patient self-management, post-discharge follow-up, and plans of care for patients who move across healthcare settings. 

New Jersey:  Health Care Quality Strategies, Incorporated is facilitating their initiative with a group of hospitals, nursing homes, home-health agencies, physician offices, inpatient rehabilitation facilities, dialysis centers, hospices, community-based organizations, and healthcare stakeholders in southwestern New Jersey.  Interventions will address issues related to medication management and reconciliation, care-planning, and care-coordination.

New York:  IPRO, Inc (IPRO) has completed an organizational profile that includes information about census, discharge disposition, re-admission rate, top-five issues/concerns related to patients who are hospitalized, and top-five reasons/underlying diagnosis for patients re-admitted to the hospital. 

Pennsylvania:  Quality Insights of Pennsylvania is currently working on a community-based, cross-setting project to help hospitals, skilled-nursing facilities, home-health agencies and physician offices improve coordination across the continuum of care. They are including community resources, such as Area Agencies on Aging to aide in the project’s success.

Rhode Island:  Quality Partners of Rhode Island’s (QPRI) approach includes: computerized education and coaching for high-risk patients and systems interventions, involving the project-team working directly with home-health agencies, hospitals, and nursing homes to implement best practices and foster effective communication among providers.

Texas:  TMF Health Quality Institute’s project is focused on collaborating with the Harlingen Hospital Referral Region (HRR) project area (cities of Brownsville, Harlingen and Weslaco) to improve patients’ transitions across care-settings to reduce avoidable hospitalizations.

Washington:  Qualis Health is partnering with several local health-care organizations to improve the safety of transferring patients across care-settings, and to reduce unnecessary hospital re-admissions. Qualis Health is targeting the community of Washington's Whatcom County.

Evaluation: 
Each local project must show evidence of improvement in the quality of care and in the implementation of strategies to reduce re-hospitalization rates. The overall evaluation for this Theme requires that multiple local projects succeed at reducing re-hospitalization rates through improved quality of care. QIOs will be evaluated on evidence that appropriate strategies were implemented early in the project and, in turn, were carried out through the entire project.

Care Transitions QIOSC: 

The Colorado Foundation for Medical Care serves as the Quality Improvement Organization Support Center.

Care Transitions:  9th SoW Measure Level (10 measures)