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.

AQIN-DC partners with healthcare professionals from all provider settings as well as patients/patient advocates and interested stakeholders to improve the quality of care for Medicare beneficiaries who transition across care settings.

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

Provider Tools and Resources

Brown Bag Toolkit


AQIN Webinar: The Imperative for Cross-Setting Coordination of Care

January 25, 2018

This educational webinar program sponsored by the Atlantic Quality Innovation Network (AQIN) of NY, SC and DC provides an overview of cross-setting care management as an increasingly important activity in the current healthcare environment. The following experts and leaders from the Centers for Medicare & Medicaid Services (CMS) 11th Scope of Work Coordination of Care and Medication Safety Tasks provide insight into the national perspective on care transitions, preventable readmissions, medication management and the importance of healthcare provider and community stakeholder participation in this work.

Traci Archibald,
OTR/L, MBA / Director, Division of ESRD, Population and Community Health
CMS / Quality Improvement and Innovation Group

Anita Thomas, Pharm.D.
U.S. Department of Health and Human Services
CMS / Center for Clinical Standards and Quality
Quality Improvement and Innovation Group/DBHIS

Jane Brock, MD, MSPH / Clinical Director
Telligen/ Quality Innovation Network-National Coordinating Center

Rachel Digmann, Pharm.D, BCPS / Medication Safety & Program Lead
Telligen / Quality Innovation Network-National Coordinating Center

Recorded Webinar

For a copy of the presentation slides, please email Janet Jones at





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Janet Jones, Project Manager