Care Transitions

Overview

The Care Transitions 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.

QIOs will work to reduce unnecessary readmissions to hospitals that may increase risk or harm to patients and cost to Medicare. CMS will look to QIOs to implement projects that effect process improvements to address issues in medication management, post-discharge follow-up, and plans of care for patients who move across health care settings.

Opportunity for Quality Improvement

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 related to discharges than to any other aspect of care that CMS measures. This situation can be changed. In general, rehospitalization rates and health care utilization vary substantially across geographic locations, suggesting opportunities for improvement in areas with higher observed rates. Improved health care processes at and after discharge correlate with substantial reductions in early rehospitalization for particular conditions, such as heart failure. In addition, prior and ongoing QIO work has assisted providers in analyzing data and in identifying and addressing gaps in care in areas such as transitions and end-of-life planning and care.

QIO Activities

The activities under the Care Transitions Theme will focus on three Tasks:

Community and provider selection and recruitment;
Interventions and;
Monitoring.

Within one month of the contract being awarded, QIOs must provide an initial report to CMS that characterizes the selected target population for which the QIO will aim to reduce readmission rates. The report will give examples of inappropriate or wasteful services affecting rehospitalization rates, describe how health services are delivered to the target population, and specify any opportunities to address disparities.

QIOs will implement quality improvement initiatives throughout their local communities concerning quality care for Medicare beneficiaries at or after hospital discharge. Each QIO is required to work with partners to implement each of the following: hospital and community system-wide interventions (designed to address system-level weaknesses), interventions that target specific diseases or conditions (focused on evidence-based practices and processes designed to have an impact on rehospitalization rates for particular conditions such as acute myocardial infarction, congestive heart failure, or pneumonia), and interventions that target specific reasons for admission (tailored to address the causes that drive local readmission rates).

Based on the findings from the initial report, and in addressing each of the three focus areas, QIOs will partner with appropriate community health care providers to develop and implement an evolving intervention plan, which will aim to reduce rehospitalization among the targeted population defined in the QIO's initial report.

Throughout the intervention period, each QIO will be accountable for ongoing project management and facilitation. The QIO will assist providers and the community in creating resources for more effective transitions and in implementing improvement activities beyond the period of hospital discharge.

QIOs will be responsible for periodic reports updating CMS on progress in the activities of this Theme.

Evaluation

Each local project must show evidence of improvement in the quality of care and in the implementation of strategies to reduce rehospitalization rates. The overall evaluation for this Theme requires that multiple local projects succeed at reducing rehospitalization 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.

Resources

MedQIC: http://www.medqic.org (click on "Care Coordination")

The Dartmouth Atlas of Health Care: http://www.dartmouthatlas.org

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