Past Success

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

From August 2008 through July 2011, IPRO led a care transition initiative in five NYS counties: Rensselaer, Saratoga, Schenectady, Warren, and Washington. We were one of 14 Medicare Quality Improvement Organizations (QIOs) funded by the Centers of Medicare & Medicaid Services (CMS) to improve care transitions and reduce unnecessary readmissions to hospitals in selected communities. IPRO’s care transition team adopted a multi-faceted community-wide approach that included healthcare and community-service organizations, physicians, and Medicare beneficiaries. This team succeeded in reducing 30-day hospital readmissions by breaking down barriers between health provider settings, implementing evidence-based interventions, and promoting shared responsibility for patient wellness.

The Remington Report featured an article profiling the IPRO Care Transitions Project in its May/June 2010 edition. Visit the site of our partners, the Colorado Foundation for Medical Care, to read the article.

In April 2009 IPRO honored a select group of healthcare providers in the Upper Capital Region who signed on to participate in the three-year project aimed at making dramatic improvements in care transitions and reducing avoidable re-admissions to hospitals.

  • IPRO press release on Care Transitions Project providers

The Journal of the American Medical Association January 23/30, 2013, Vol 309, No.4 

Association Between Quality Improvement for Care Transitions in Communities and Rehospitalizations Among Medicare Beneficiaries



Cardiovascular Health
Cardiovascular Health (DC)
Cardiovascular Health (NY)
Cardiovascular Health (SC)
Care Coordination
Care Coordination DC
Care Coordination NY
Beneficiaries and Families
Healthcare Professionals
Other Website Resources
Tools and Resources
Past Success
Upcoming Events
Past Events
Contact Us
Care Coordination SC
Community Based Sepsis
Educational Webinar Programs
Sepsis in the News
Tools and Resources
Diabetes Self-Management
EDC Foot Care Campaign
Diabetes Self-Management Education (DC)
Diabetes Self-Management Education (NY)
Drug Safety
Anticoagulation Safety
Hypoglycemia Avoidance
Opioid Safety
Opioid Safety (DC)
Opioid Safety in Community Pharmacy
Drug Safety (DC)
Drug Safety (NY)
Drug Safety (SC)
Immunization (DC)
Immunization (NY)
Immunization (SC)
SC Immunization Coalition Materials
Nursing Home Quality
Nursing Home Quality (NY)
QAPI Self-Assessment
Eliminating Inappropriate Antipsychotic Medication Use
Clinical Quality Measures (QM)
Composite Measure Score
NHQCC Collaborative I Kick-Off
NHQCC Collaborative I Outcomes Congress
Using a System's Approach to Quality & Performance Improvement
Nursing Home Quality Care Collaborative (NHQCC) Learning
Engaging Staff in Individualized Care
QAPI Self-Assessment and Related Resources
QAPI In Action
Quality Improvement (QI) Resources
Quality Improvement Strategies
Steps to QAPI
Elements for Framing QAPI in Nursing Homes
Clinical Topics
Medication Use Tools & Resources
Pressure Ulcer Clinical Tools & Resources
Restraint Clinical Tools & Resources
Falls with Major Injuries
Health Care Acquired Conditions
Eliminating Long Term Care Re-Admissions Tools & Resources
Nursing Home Quality (DC)
Nursing Home Quality (SC)
ACE e-Newsletter
Clinical Topics
Organizational Change
Presentations and Handouts
Upcoming Events
Outpatient Antibiotic Stewardship
Core Element One: Commitment
Core Element Two: Action for Policy and Practice
Core Element Three: Tracking and Reporting
Core Element Four: Education and Expertise
Quality Payment Program
QPP Support for Large Practices
QPP Support for Small Practices
CMS Webinars & Programs
Request Free Technical Assistance
QPP Education
QPP General Information
Quality Measures
Improvement Activities (IA)
Promoting Interoperability (PI)
Transforming End of Life

Contact Us

New York

Sara Butterfield, Senior Director

Christine Stegel, Senior Quality Improvement Specialist

Fred Ratto Jr., Quality Improvement Specialist