Integrate Care for Populations and Communities

Improving Care Transitions Leading to the Reduction of Readmissions

This Care Transitions project is a Center for Medicare and Medicaid Services (CMS) three year national initiative focused on reducing the rate of hospital readmissions within 30 days of discharge by 20% among Medicare beneficiaries. 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 in discharge-related care than in any other aspect of care that CMS measures¹. Within 30 days of discharge, 17.6 percent of Medicare beneficiaries are re-hospitalized, and the Medicare Payment Advisory Commission (MedPAC) estimated that up to 76 percent of these readmissions may be preventable. Of Medicare beneficiaries who are readmitted within 30 days, 64% receive no post-acute care between discharge and readmission².

FMQAI will partner with healthcare providers and their communities to measurably improve the quality of care for Medicare beneficiaries who transition among care settings. The QIO will assist in facilitating and coordinating these relationships to ensure community-wide adoption of improved care transition practices. Our efforts aim to yield sustainable and replicable strategies to achieve high-value health care for sick and disabled Medicare beneficiaries.

Addresses the lack of standard known discharge processes to transfer responsibility of patients to the next healthcare setting
Improves cross-setting communication
Fosters improvement in patients’ self management skills, outcomes and satisfaction with the healthcare transition experiences
Promotes implementation of evidence based interventions to address community root causes for gaps in care transitions
Spreads innovations, patient successes and large scale improvement through participation in the statewide Learning and Action Network

The most effective interventions will depend on changes in the processes of care at a community level that engage more than one provider (including hospitals, home health agencies, dialysis facilities, nursing homes, and physician offices), as well as patients, families, and community health care stakeholders. The unit of intervention for this initiative is the community.

FMQAI was one of 14 Quality Improvement Organizations (QIOs) selected by the Centers for Medicare & Medicaid Services (CMS) to participate in the Care Transitions project (2008-2011) designed to serve target populations unique to each selected state. Lessons learned during this project are invaluable to the future success of our communities and the state to improve the quality of beneficiary care.

9^th SOW FACT SHEET: here

¹ Care Quality Information from the Consumer Perspective Hospital Survey (HCAHPS) Pilot
² MedPAC: June 2007 Report to the Congress: Promoting Greater Efficiency in Medicare.

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Medicare Contract Numbers: QIO: HHSM-500-2011-FL10C ESRD: HHSM-500-2013-NW007C