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Coordination of Care

Medicare consumers with chronic illnesses often need care from numerous doctors, nurses, and other medical professionals in multiple settings of care. They transition between hospitals, nursing homes, home health agencies, doctors’ offices and home in order to obtain the services they need.

Studies have shown that such transitions can jeopardize patient safety and quality of care as a result of incomplete and/or inaccurate transfer of information, medication discrepancies, and lack of appropriate post-acute care, leading to adverse medication events, exacerbation of chronic illness, and the inability of patients and families to recognize and react to signs of acute illness. Coordination of care is key to reducing risk and fostering optimal outcomes.

RARE Campaign - reducing avoidable hospital readmissions RARE logo

Stratis Health has joined with the Institute for Clinical Systems Improvement and the Minnesota Hospital Association in a statewide effort to prevent 4,000 avoidable readmissions within 30 days of discharge (reduce overall readmissions rate by 20 percent from the 2009 baseline) by December 31, 2012. Over 80 hospitals are participating in the campaign, working to improve patient care. RARE Campaign website

Improving transitions in care

Studies suggest that up to 76 percent of readmissions of Medicare Fee-for-Service beneficiaries within 30 days of discharge may have been preventable. As Minnesota’s Medicare Quality Improvement Organization, Stratis Health will support quality of care improvement for Medicare beneficiaries who transition among care settings through a comprehensive effort of community coalitions and learning and action networks. We will support Minnesota communities that have been selected to participate in the Improving Transitions in Care initiative to improve care coordination across settings of care and reduce avoidable hospital readmissions through July 2014. Participating communities will include interdisciplinary representatives from acute care hospitals, physician practices, long-term care facilities, home health agencies, and hospice organizations, as well as payers, consumers, and local and state officials.

Community coalitions

Stratis Health is recruiting two to three communities for intensive community level support in developing a community-based coalition with the goal of reducing 30 day readmissions by 20 percent over three years. We will provide root cause analysis support to identify community-specific causes for poor transitions; support for selection and implementation of interventions that address known drivers for improvement; technical support for application in a formal care transitions program; and quarterly readmission metrics.

Learning and action network

In partnership with the Minnesota Hospital Association and Institute for Clinical Systems Improvement, Stratis Health is leading the statewide RARE Campaign (Reducing Avoidable Readmissions Effectively), open to all hospitals in the state. This effort, which was formally launched in July 2011, will serve as a Learning and Action Network that will provide participants with conference calls, webinars, and in-person meetings. We will educate state providers, community organizations, and stakeholder groups in reducing readmissions and provide technical assistance, as well as respond to requests from providers and stakeholders.  Most of these requirements will also be met through the RARE campaign.

The following resources may assist Medicare consumers, their families and their providers in the coordination of care process.

Patient/provider communication

Personal Health Record. A simple booklet can help patients keep track of their care. Its a good place for patients to write down all the details of their care, and then share the form with their doctors and nurses. Patients should take this booklet when they go to the hospital or anytime they are receiving medical care and keep it updated with changes in medicines or treatments. (6-page PDF)

Ask Me 3. An educational program provided by the Partnership for Clear Health Communication at the National Patient Safety Foundation. Site offers provider resources on the topic of health literacy as well as downloadable patient resources aimed at improving communication with providers.

Minnesota Health Literacy Partnership. A consortium of health care consumers, literacy groups, state health and social services agencies as well as representatives from payer and provider groups. Site offers resources and opportunities for collaboration and information gathering.

Discharge planning

Discharge Checklist. The Centers for Medicare & Medicaid Services prepared this check list for patients leaving hospitals, nursing homes or other care settings. It also includes contact information for helpful organizations and agencies. (6-page PDF)

Project RED: Re-Engineering Discharge. The Project RED intervention re-engineers discharge workflow processes and provides a set of 11 discrete, mutually reinforcing components. The Project RED Toolkit contains tools to facilitate a re-engineered hospital discharge including the After Hospital Care Plan as well as a training manual.

Be Prepared: Reducing Nursing Home Transfers Near End of Life. A recent regional initiative by the California Health Care Foundation, the PREPARED project, sought to reduce transferring nursing home residents to a hospital and the end of life. By improving advanced-care planning, including use of Physician Orders for Life Sustaining Treatment, unnecessary suffering and the potential for increased health care costs were reduced. The complete issue brief is available as a download.

Additional resources

Best Practice Intervention Package: Cross Settings II, from Home Health Quality Improvement (HHQI), offers information on improving care transition for chronic-care patients through disease management, self-care management and telehealth. Also available are HHQI Success Stories in which home health agencies discuss their successes with improving care transition, disease management and telehealth. A free registration allows you to review all of this information and much more. Register >

Care Transitions Intervention Web Site. Under the leadership of Eric Coleman, MD, the aim of the Care Transitions Program is to support patients and families, increase skills among health care providers, enhance the ability of health information technology to promote health information exchange across care settings, implement system level interventions to improve quality and safety, develop performance measures and public reporting mechanisms, and influence health policy at the national level.

Care Transitions Success Stories and Lessons Learned. Describes care transitions success stories and includes major themes for improving care transitions and reducing potentially avoidable hospital readmissions. It is meant to be a practical resource to foster community-based interventions and innovation for improving care transitions. It is grounded in analysis and lessons learned from Stratis Health’s leadership role in four care transitions initiatives that occurred between 2011 and 2014: 1) Reducing Avoidable Readmissions Effectively (RARE) Campaign, 2) Community-based “Improving Transitions of Care” initiative, 3) Care Coordination for Rural Accountable Care Organizations, and 4) Health Information Technology for Post-Acute Care Providers (HITPAC) project. (18-page PDF) Care Transitions Success Stories and Lessons Learned presentation (54-minute webinar)

Coordination of Care Measures from AHRQ. The Agency for Healthcare Research and Quality has released a new resource for persons interested in measuring care coordination, an emerging field of quality measurement. The Care Coordination Measures Atlas is available online and for download in pdf format (286-page PDF). It identifies more than 60 measures for assessing care coordination that include the perspectives of patients and caregivers, health care professionals, and health system managers. This free new resource:

  • Provides a list of existing measures of care coordination.
  • Includes measures of patient and caregiver experiences with care coordination, as well as those of health care professionals and health system managers.
  • Features measures that are mapped to a conceptual framework linked to key domains, which are important in measuring care coordination.
  • Contains a five-step Jumpstart Guide users can follow to identify existing measures of care coordination that may meet their particular needs.

H2H National Quality Improvement Initiative. The Hospital to Home (H2H) national quality improvement initiative, led by the American College of Cardiology and the Institute for Healthcare Improvement, is a national rallying point to reduce cardiovascular-related hospital readmissions and improve the transition from inpatient to outpatient status for individuals hospitalized with cardiovascular disease.

Health Research and Educational Trust. A website dedicated to identifying, exploring, demonstrating, and evaluating key strategic health care issues affecting innovative health care delivery systems, educating the field about the implications of changing health policies and developing strategies for community health improvement.

How-to Guide: Creating the Ideal Transition Home for Patients with Heart Failure. This online guide builds upon relevant research and published literature, and integrates what Transforming Care at the Bedside hospitals have learned as they strive to dramatically improve the quality of care for patients discharged from the hospital to home or to another health care facility.

Interventions to Reduce Acute Care Transfers (INTERACT). The program provides tools and resources that can help to reduce avoidable acute care transfers. Developed through a project supported by the Commonwealth Fund based at Florida Atlantic University, the program is built around a number of practical tools designed to improve care coordination and transitions of care.

Medicare-Medicaid Coordination Office. The office serves people who receive benefits from both Medicaid and Medicare. Its goal is to make sure dual-eligible beneficiaries have full access to seamless, high-quality health care and to make the system as cost-effective as possible.

National Transitions of Care Coalition. Formed in 2006, brings together thought leaders, patient advocates, and health care providers from various care settings dedicated to improving the quality of care coordination and communication when patients are transferred from one level of care to another. This site offers information and resources for patients, health care professionals, and policy makers.

Potentially Preventable Hospitalizations Among Minnesotans, 2007. This brief, published by the Minnesota Department of Health Health Economics Program provides information about potentially preventable hospitalizations in Minnesota for 2007, including estimates of cost associated with these hospitalizations.  It also shows how rates for select conditions leading to potentially preventable hospitalizations vary across the state. (12-page PDF)

Project BOOST: Better Outcomes for Older Adults through Safe Transitions. The Society of Hospital Medicine launched Project BOOST to improve care of older patients as they transition from the hospital to home or another care facility. The project uses a team approach to assess patients’ risk for re-hospitalization and plan and execute risk-specific discharge planning activities. This site offers a comprehensive resource room, covering planning, best practices, education resources and clinical tools.

Rural Emergency Department Transfer Communication. Stratis Health led a one-year national special innovation project funded by the Centers for Medicare & Medicaid Services for Critical access hospitals (CAH) in eight states to improve transitions of care during emergency department (ED) transfers. The project ran August 2013 - July 2014.

Safer Handoff. A practical guide to safer handoff of older adult patients between long term care facilities and emergency departments. These valuable guidelines provide emergency nurses, long-term care nurses, and emergency medical services professionals with tools to ease the development of standardized communications to improve older adult patients’ handoffs.

Skilled Nursing Facility Guide to Field Testing: Creating an Ideal Transition to a Skilled Nursing Facility. Created by the Institute for Healthcare Improvement with funding from the Commonwealth Fund to support individuals and organizations in their work to improve transitions in care. (42-page PDF)

STate Action on Avoidable Rehospitalizations Initiative. The STate Action on Avoidable Rehospitalizations (STAAR) initiative aims to reduce rehospitalizations in Massachusetts, Michigan, Ohio, and Washington, and by engaging payers, state and national stakeholders, patients and families, and caregivers at multiple care sites and clinical interfaces.

Transitions of Care in the Long-Term Care Continuum. Clinical practice guidelines developed under a project conducted by the
American Medical Directors Association, the national professional organization representing medical directors, attending physicians, and other practitioners who care for patients in the long-term care setting. (80-page PDF)

Contact Stratis Health for assistance with your quality improvement and patient safety needs.

If your organization has projects it would like to work on, contact us to discuss how we can work together to support coordination of care initiatives.

Janelle Shearer, program manager