Care Coordination

   Improving Transitions of Care

New York South Carolina Washington D.C.

Avoidable hospital readmissions, lack of patient satisfaction and comprehension of discharge plans are growing problems nationwide. National research shows that 17.5 percent of Medicare beneficiaries are re-hospitalized within 30 days of a hospital discharge. Of those patients who are re-admitted, the Medicare Payment Advisory Committee estimates that 64 percent received no post-acute care between discharge and readmission and projects that 76 percent of readmissions may be preventable. Furthermore, the Centers for Medicare & Medicaid Services' (CMS) research shows beneficiaries report greater dissatisfaction in discharge-related care than any other aspect of care.

A Community-Based Approach

The Atlantic Quality Innovation Network, (AQIN), under contract with CMS, approaches improvement of care coordination by establishing and working with coalitions at the community level, where the Medicare Beneficiaries needs are best met. Healthcare and community providers involved in all aspects of the beneficiary’s care are invited to be active Coalition members: hospitals, skilled nursing facilities, home health agencies, hospice, assisted living facilities, physicians, payers, patients, caregivers, community service agencies and other key stakeholders. Together, issues are identified and solutions are developed to address improved care transitions across all settings, from hospital discharge, to rehabilitation, home health care and into the community with additional supports.

AQIN knows that collaboration, partnership, and working with and helping others is the essence of success across the healthcare continuum for implementation of evidenced based interventions and best practices that improve care transitions for Medicare beneficiaries in the community. Such opportunities for improvements are:

• Improvements in transfer of information between providers and patients during transitions.
• Patient and caregiver understanding of medications and their treatment plans.
• Assessment of patient/caregiver resources and management of condition in community for care planning purposes.
• Standardization of processes to effectively manage the transition of the patient between settings.

In an effort to reduce adverse drug events and the associated consequences of patient harm, the Coordination of Care Drug Safety Team is assisting healthcare providers and communities to objectively evaluate their medication reconciliation and management processes and assist with implementing interventions to reduce adverse drug events and promote medication safety and best practices. There will be an added focus on high-risk drug groups including opioids, diabetic agents, and anticoagulants.

Patients are at particularly high risk of medications errors and adverse drug events as they transition between care settings, and specific high-risk drug classes warrant specific attention. For more information on efforts to reduce adverse drug events associated with high-risk drugs visit the AQIN Drug Safety page.

Our Commitment

With the continued goal of improving care coordination through quality improvement, the Coordination of Care Initiative moves forward to support new and existing healthcare communities, Medicare Beneficiaries and their families, and caregivers with the following goals:

• Improve the quality of care for patients who transition among health care settings through a comprehensive community effort.
• Raise community awareness of the need for patients to be more involved and “patient-centered” in their health care, especially as they transition from one health care setting to another during care transitions. Assistance and support will be provided to patients, families, and caregivers with the resources and tools.
• Assist health care professionals in working together across settings to ensure patient-centered care.

AQIN’s Coordination of Care Project Team is providing free consultative services to health care professionals to:

• Work collaboratively within the community with the patient at the center of attention;
• Improve communication between provider settings to strengthen care coordination;
• Streamline secure access to important patient specific information across provider settings;
• Increase patient/caregiver satisfaction regarding the transition process between care settings;
• Decrease medication discrepancies and adverse drug events during the transition process.

AQIN is working to engage patients and their family caregivers to:

• Enhance understanding of medications and prescribed medical regimen;
• Connect with primary care and community resources;
• Engage with healthcare providers and practitioners to become actively involved in their plan of care
• Implement and maintain a standardized method to record personal health care information

Key Strategies & Interventions

AQIN envisions the transition of patients/residents between health care settings and practitioners in our communities will be well coordinated between all institutions, practitioners and community service organizations with the patient and caregiver as the center of care. AQIN is committed to collaborate and provide technical assistance to communities:

• To build and sustain a cross-setting interdisciplinary coalition with a focus on improving transitions of care
• To be a vehicle for the patient and family voice
• To encourage person-centered and person-directed models of care
• To collaborate and encourage efforts of organizations with shared visions

In joining the Readmissions Network, participants will:

• Commit to active involvement in performing a community root cause analysis to identify readmission drivers, adopt evidence-based interventions to address the readmission drivers and conduct internal monitoring on a quarterly basis to track the effectiveness of the interventions.
• Partner as a community to share best practices, knowledge, and findings from ongoing monitoring of readmission drivers.
• Agree to provide senior leadership and Board engagement and support organizational resources to establish an internal interdisciplinary team.
• Actively participate and attend in-person Coalition meetings that shall be held at least quarterly.
• Participate in live, web-based educational forums to learn and share best practices with other network members.