Improving Care Transitions and Reducing Hospital readmissions: Establishing the Evidence for Community-Based Implementation Strategies Through the Care Transitions Theme
The Care Transitions Theme is a CMS-funded initiative for Medicare Quality Improvement Organizations (QIOs) to measurably improve the quality of care for Medicare Beneficiaries who transition among care settings through a comprehensive community effort. Fourteen QIOs began working with target communities within their respective States on August 1st, 2008, and the project will be completed by August 2011. Each QIO selected a specific geographic area and a Medicare beneficiary population (as defined by beneficiary zip code of residence) where they are now working with the medical services providers, other community health support agencies, unpaid caregivers and patients to identify drivers of poor transitional care and to reduce their influence on patient outcomes. In other words, this work seeks to improve care quality by promoting seamless transitions among care settings, and thereby reduce readmissions to hospitals within 30 days of discharge.