Created by Qualidigm, the Care Transitions Initiative supports hospitals in Connecticut that are working on systemic changes to decrease readmissions and improve the quality of follow up care after discharge.

Challenge:

Nearly one in five Medicare patients is readmitted to the hospital within 30 days of discharge, and many of these readmissions are preventable. The Centers for Medicare and Medicaid Services (CMS) considers readmissions to the hospital a key indicator of an overly expensive and uncoordinated health system, and has instituted financial penalties to hospitals with high readmission rates.

Solution:

Qualidigm launched the Care Transitions Initiative to support hospitals in Connecticut that are working on systemic changes to improve the quality of follow up care after discharge – deterring or preventing patients from being readmitted to the hospital. After forming numerous geographic areas in Connecticut known as Communities of Care that include a hospital(s) and their associated nursing facilities, home health agencies, physicians, and community-based organizations with which they share patients, Qualidigm consultants continue to actively provide technical assistance in community building, clinical expertise across the continuum of care, and knowledge of the science and practical application of quality and safety intervention strategies.

Qualidigm’s proven approach focuses on identifying failures in communication or coordination of care gaps between health care settings and standardizing systems that include the critical information that should accompany every patient as they move from one health care setting to another or return home.

Benefit:

Qualidigm has provided opportunities (including the Care Transitions Leadership Academy workshop series) for healthcare providers from all settings to build relationships, learn best practices for patient care transitions, and adopt systems to coordinate care during patient transfers, resulting in better patient care and reduced readmissions to the hospital.