Care Transitions

Nearly one in five Medicare patients is readmitted to the hospital within 30 days of discharge. Many of these readmissions are both preventable and needlessly affect patients’ quality of life, as well as burden our health care delivery system. By standardizing the provision of care to patients within and across care settings, and engaging patients and their families as active care partners, it is possible to reduce unnecessary hospital readmissions.

Between February 2010 and February 2012, Qualidigm and the Connecticut Hospital Association (CHA) collaborated on an initiative to decrease preventable hospital readmissions for patients with heart failure. CHA took the lead on assisting 24 hospitals with internally-focused quality improvement activities, while Qualidigm convened and provided technical assistance to 15 of these hospitals and a variety of community partners to improve transitions between settings of care. These “Communities of Care” included hospitals, nursing homes, home health agencies, physicians, and other community-based organizations that share patients. Together, the collaborating organizations brought about significant improvements in the process of caring for patients with heart failure across the continuum of care and important decreases in hospitalizations.

In February 2012, this collaboration was renamed the Care Transitions Initiative and broadened to address preventable hospitalizations of all patients across Connecticut. Qualidigm and CHA have continued to support existing and new communities with education and technical assistance on evidence-based quality improvement strategies in one-on-one and group settings. Highlighted strategies include: use of data to identify opportunities for improvement; enhanced communication between settings; timely post hospitalization physician visits; standardized patient/family education; emergency care plans; medication reconciliation; standardized protocols for care coordination; and palliative care.  The strategies that are chosen are based on the specific needs of each community.

In August 2014, Qualdigm expanded its care coordination services to address similar issues through a collaboration with HealthCentric Advisors of Rhode Island.  Under a new CMS contract, targeted strategies to reduce readmission rates and improve care in the rural states of Vermont and New Hampshire will benefit the Medicare beneficiaries in those regions.

For more information, contact:

Anne Elwell, RN, MPH, Principal and Vice President of Community Relations