Initiative

The Community-Based Care Transitions Program, a provision of the newly enacted Patient Protection and Affordable Care Act (Section 3026 of HR 3590), provides $500 million to collaborative partnerships between hospitals and community-based organizations designed to meet the goal of implementing evidence-based care transitions services for Medicare beneficiaries at high risk for hospital readmission. The provision in the law grew out of a successful translation of the Care Transitions Intervention model into practice settings nationwide. The translation of the model was made possible by funding from the John A. Hartford Foundation, a national funder located in New York City. (The model itself was designed with funding from Hartford and the Robert Wood Johnson Foundation.) Fourteen states, under a Centers for Medicare and Medicaid Services (CMS) contract, have tested the model, and many have experienced significant reductions in hospital readmissions. Eric A. Coleman, a professor of medicine at the University of Colorado Denver, directs the broader Care Transitions Program and has led the model’s development and translation efforts. This intervention “helps smooth the transition from hospital to home,” explained Amy Berman, a program officer at the Hartford Foundation, in a 23 September 2009 post on the foundation’s blog, Health AGEnda . It works by encouraging older patients to take a more active role in their own care. The Community-Based Care Transitions Program is on schedule for implementation in early 2011. Eligible hospitals and community-based organizations that forge a partnership committed to implementing evidence-based care transitions services—such as the Care Transitions Intervention described above—may apply to the secretary of the Department of Health and Human Services (HHS) for funding. The program’s success will be assessed through an evaluation of hospital readmission rates for high-risk Medicare beneficiaries receiving services from the program over a five-year period.

August 16, 2019

Improving Care Transitions: A Key Component of Health Reform

The Community-Based Care Transitions Program, a provision of the newly enacted Patient Protection and Affordable Care Act (Section 3026 of HR 3590), provides $500 million to collaborative partnerships between hospitals and community-based organizations designed to meet the goal of implementing evidence-based care transitions services for Medicare beneficiaries at high risk […]
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The Community-Based Care Transitions Program, a provision of the newly enacted Patient Protection and Affordable Care Act (Section 3026 of HR 3590), provides $500 million to collaborative partnerships between hospitals and community-based organizations designed to meet the goal of implementing evidence-based care transitions services for Medicare beneficiaries at high risk for hospital readmission. The provision in the law grew out of a successful translation of the Care Transitions Intervention model into practice settings nationwide. The translation of the model was made possible by funding from the John A. Hartford Foundation, a national funder located in New York City. (The model itself was designed with funding from Hartford and the Robert Wood Johnson Foundation.) Fourteen states, under a Centers for Medicare and Medicaid Services (CMS) contract, have tested the model, and many have experienced significant reductions in hospital readmissions. Eric A. Coleman, a professor of medicine at the University of Colorado Denver, directs the broader Care Transitions Program and has led the model’s development and translation efforts. This intervention “helps smooth the transition from hospital to home,” explained Amy Berman, a program officer at the Hartford Foundation, in a 23 September 2009 post on the foundation’s blog, Health AGEnda . It works by encouraging older patients to take a more active role in their own care. The Community-Based Care Transitions Program is on schedule for implementation in early 2011. Eligible hospitals and community-based organizations that forge a partnership committed to implementing evidence-based care transitions services—such as the Care Transitions Intervention described above—may apply to the secretary of the Department of Health and Human Services (HHS) for funding. The program’s success will be assessed through an evaluation of hospital readmission rates for high-risk Medicare beneficiaries receiving services from the program over a five-year period.
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https://www.healthaffairs.org/do/10.1377/hblog20100429.004893/full/

August 8, 2019

Interventions to Reduce Acute Care Transfers (INTERACT)

Florida Atlantic University. INTERACT. Interventions to Reduce Acute Care Transfers. Commonwealth Fund. http://interact2.net/. Updated February 7, 2011. Accessed July 25, 2014. INTERACT is a quality improvement program designed to improve the early identification, assessment, documentation, and communication about changes in the status of residents in skilled nursing facilities. The goal […]
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Florida Atlantic University. INTERACT. Interventions to Reduce Acute Care Transfers. Commonwealth Fund. http://interact2.net/. Updated February 7, 2011. Accessed July 25, 2014. INTERACT is a quality improvement program designed to improve the early identification, assessment, documentation, and communication about changes in the status of residents in skilled nursing facilities. The goal of INTERACT is to improve care and reduce the frequency of potentially avoidable transfers to the acute hospital. Such transfers can result in numerous complications of hospitalization, and billions of dollars in unnecessary health care expenditures.
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http://interact2.net/#

August 8, 2019

Community Collaborative Improves Accuracy of Medication Lists for Elderly Patients in Outpatient Clinic Setting. Aurora Healthcare, Milwaukee Wisconsin

Agency for Healthcare Research and Quality. Aurora Health Care. http://www.innovations.ahrq.gov/content.aspx?id=1766. Accessed 4/16/13. Community Collaborative Improves Accuracy of Medication Lists for Elderly Patients in Outpatient Clinic Setting. A community-wide medication reconciliation collaborative, involving health care consumers, providers, pharmacists, and community stakeholders, gave elderly patients and their providers the tools and education […]
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Agency for Healthcare Research and Quality. Aurora Health Care. http://www.innovations.ahrq.gov/content.aspx?id=1766. Accessed 4/16/13. Community Collaborative Improves Accuracy of Medication Lists for Elderly Patients in Outpatient Clinic Setting. A community-wide medication reconciliation collaborative, involving health care consumers, providers, pharmacists, and community stakeholders, gave elderly patients and their providers the tools and education needed to assemble and verify accurate medication lists and communicate effectively to prevent medication errors. As a result, the rate of accurate medication lists among targeted patients improved from 55 percent to 72 percent. Evidence Rating Moderate: The evidence consists primarily of before and after comparisons of the accuracy of medication lists and comparison with controls, which included Aurora practices in which there was no intervention and post-implementation surveys eliciting patient and provider views. Although the project provided extensive education and support and employed controls, a direct causal link between the program and the improved accuracy rates cannot be confirmed, as confounding variables may have influenced the results, including recent emphasis and education by professional organizations.
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http://www.innovations.ahrq.gov/content.aspx?id=1766

August 7, 2019

IHI Collaborative: Hospital to home, Optimizing the Transition

IHI has found that a comprehensive and reliable discharge plan, along with post discharge support, can reduce readmission rates, improve health outcomes and assure quality transitions. The goal of this Web&ACTION is to work with teams to optimize communications, support and involve patients and families, and eliminate waste and improve […]
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IHI has found that a comprehensive and reliable discharge plan, along with post discharge support, can reduce readmission rates, improve health outcomes and assure quality transitions. The goal of this Web&ACTION is to work with teams to optimize communications, support and involve patients and families, and eliminate waste and improve workflow using ideas that have been tested on the discharges of patients with heart failure (HF) on medical-surgical units. Upon completion of this Web&ACTION, participants will be able to: • Reduce unplanned admissions for patients with heart failure • Understand and collect key data regarding hospital readmissions • Describe and test top ideas for reducing heart failure readmissions to hospitals • Increase patient involvement in their care while in the hospital and after discharge
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http://www.ihi.org/knowledge/Pages/Tools/TCABHowToGuideTransitionHomeforHF.aspx

August 7, 2019

Hospital to Home (H2H): Excellence in Transitions

An initiative of the American College of Cardiology and the Institute for Healthcare Improvement, Hospital to Home (H2H) is a national improvement initiative that aims to reduce unnecessary readmissions and improve care transitions for cardiovascular patients. The goal is to reduce all-cause readmission rates among patients discharged with heart failure […]
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An initiative of the American College of Cardiology and the Institute for Healthcare Improvement, Hospital to Home (H2H) is a national improvement initiative that aims to reduce unnecessary readmissions and improve care transitions for cardiovascular patients. The goal is to reduce all-cause readmission rates among patients discharged with heart failure or acute myocardial infarction by 20 percent by December 2012.
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http://www.h2hquality.org/

August 7, 2019

Joint Commission Center for Transforming Healthcare Releases Tool to Tackle Miscommunication Among Caregivers

The Joint Commission Center for Transforming Healthcare released a new Hand-off Communications Targeted Solutions Tool™ (TST) to assist health care organizations with the process of passing necessary and critical information about a patient from one caregiver to the next, or from one team of caregivers to another, to prevent miscommunication-related […]
The Joint Commission Center for Transforming Healthcare released a new Hand-off Communications Targeted Solutions Tool™ (TST) to assist health care organizations with the process of passing necessary and critical information about a patient from one caregiver to the next, or from one team of caregivers to another, to prevent miscommunication-related errors.
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http://www.centerfortransforminghealthcare.org/center_transforming_healthcare_tst_hoc/