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

The Coordination of Care Initiative focuses on collaboration with cross-setting health care providers, community-based organizations and healthcare consumers to improve communication and care coordination for Medicare Beneficiaries. The IPRO Coordination of Care project team has been working on improving transitional care in NYS over the past seven years, which has resulted in many positive outcomes, improvements in care management and a decrease in hospital readmissions for Medicare Beneficiaries. IPRO has built the foundation for this work on bringing healthcare providers from various settings together to evaluate existing transitional care systems and processes with emphasis on building partnerships and collaboration amongst hospitals, home health agencies, nursing homes, dialysis centers, physician offices, community service organizations, and consumers. We promote and support the implementation of evidenced based interventions and best practices that improve care transitions for Medicare beneficiaries in the community.

Nationally almost 20% of Medicare beneficiaries are readmitted to the hospital within 30 days of discharge. It is estimated that up to 76% of these re-hospitalizations may be preventable and result in heavy costs to the healthcare system and contribute to poor healthcare quality, adverse advents, and a burden to patients and their families. (Source: MedPAC: June 2007 Report To Congress: Promoting Greater Efficiency in Medicare.) Through cross-setting care transitions efforts, hospital readmissions have declined from 19% in 2011 to 17.9% nationally in 2013, with an estimated 150,000 fewer readmissions and broad-based improvements across geographic, demographic and clinical outcomes.

As of August 2014, the Centers for Medicare & Medicaid Services 11th Scope of Work, a five year quality improvement initiative, began its national mission to reduce hospital admissions and readmissions by 20% in participating communities and increasing community tenure for Medicare Beneficiaries through greater collaboration of community-based supports and services.  Emphasis is placed on Medicare beneficiaries with multiple chronic conditions, health literacy needs, those living in rural areas, and those who will benefit the most from the transformation of the healthcare system into one in which coordinated care is the norm.

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.    With the continued goal of improving care coordination through quality improvement, the coordination of Care Initiative moves forward to assist new and existing healthcare communities, patients, families and their caregivers.

Comments or Questions? Please contact us.

More Information for Healthcare Professionals

If you are a healthcare professional and are interested in learning more about the work we’re doing to improve transitions of care in New York State, please visit our Healthcare Professionals section and explore IPRO’s wide variety of Care Transitions tools and resources.

Empowering Medicare Beneficiaries and Families

IPRO’s work in improving care transitions includes efforts to engage Medicare beneficiaries by providing information they need to educate themselves about their role in ensuring effective transitions of care and in self-managing their chronic illness. We conduct outreach, both directly to beneficiaries and through their healthcare providers, to see that they have access to these resources. For more information about resources for beneficiaries and families, visit the Beneficiaries and Families section of our website.


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Contact Us

New York

Sara Butterfield, Senior Director

Christine Stegel, Senior Quality Improvement Specialist

Fred Ratto Jr., Quality Improvement Specialist