Care Transitions: An Introduction

TMF Health Quality Institute is conducting a Care Transitions project in the Lower Rio Grande Valley to measurably improve the quality of care of Medicare beneficiaries who transition between care settings. TMF is focusing on improving coordination of care between providers and across the continuum of care by promoting seamless transitions from the hospital to home, skilled nursing care, home health care or other providers to prevent avoidable rehospitalization.

Care Transitions is the process by which patients move from hospitals to other care settings. It is increasingly problematic, and Medicare patients report greater dissatisfaction in discharge-related care than in any other aspect of care that CMS measures.

Within 30 days of discharge 17.6 percent of these patients are re-hospitalized, and the Medicare Payment Advisory Commission (MedPAC) estimates that up to 76 percent of these hospital readmissions may be preventable1.

Of Medicare beneficiaries who are readmitted within 30 days, 64 percent receive no post-acute care between discharge and readmission1. Older patients with chronic illnesses often require care from a variety of practitioners in multiple settings, yet many settings are disconnected from others, creating potential quality gaps.

TMF is working with health care providers in the Valley to implement interventions that result in process improvements and address issues in medication management, post-discharge follow-up, communication and coordination of care. The Care Transitions project will promote increased self-management of chronic disease for patients and their caregivers through education, support and a patient health care record as patients move across community health care settings.

Fact Sheet: Medicare QIOs and Care Transitions

TMF Health Quality Institute is one of 14 Quality Improvement Organizations (QIOs)that is engaging health care providers on the local level to improve care coordination and quality. To learn more about the Care Transitions Project, read this Medicare Fact Sheet (523kbs PDF).

How to Participate

Health care providers in the Lower Rio Grande Valley cities of Brownsville, Harlingen and Weslaco are invited to participate in this innovative health care improvement project. Hospitals, home health agencies, hospices, skilled nursing facilities, physicians and inpatient rehab facilities all play vital roles in the long-term success of this project, and their participation is encouraged.

To submit a participation agreement, click here.

Contact Information

Contact TMF staff toll-free at 1-866-439-6863.

General e-mail: CareTransitions@tmf.org

Fax: 512-334-1775

Click here for individual staff contact information.

Sources

1 MedPAC, "Report to the Congress: Promoting Greater Efficiency in Medicare," June 2007.