Improving Transitions of Care (DC)

Improving coordination of healthcare, communication and patient/caregiver knowledge by fostering community-based coalitions, teamwork and patient-centered care.

Reducing Preventable Hospital Readmissions in Communities Across the District

Avoidable hospital readmissions place a physical and emotional burden on patients and their families. They also drain the Medicare Trust Fund an estimated $12 billion annually. Soon, they will create a financial liability for hospitals that accept Medicare payment.

Approximately one in five Medicare beneficiaries is re-hospitalized within 30 days of discharge, in part because 64 percent of them received no post-acute care between discharge and readmission. Not surprisingly, a growing number of healthcare providers and patient advocates are focusing increased attention on improving transitions of care following discharge, be it to the patient’s home, a nursing home, home health agency, or other community-based facility.

Delmarva Foundation invites healthcare professionals from all provider settings as well as patients/patient advocates and interested stakeholders to become partners in this important community-based initiative to improve the quality of care for Medicare beneficiaries who transition among care settings.

Delmarva Foundation staff members are also available to consult with community care transitions organizations/coalitions who are interested in applying for federal funding to support their efforts.




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Core Element One: Commitment
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District of Columbia

Janet Jones, Project Manager