Care Transitions Project - An Overview
Almost one in five patients discharged from a hospital in the United States -- 19.6 percent -- are readmitted within 30 days. As hospitals shorten lengths of stay and care becomes more fragmented, the process by which patients move from hospitals to other care settings is increasingly problematic. Medicare patients report greater dissatisfaction related to discharges than to any other aspect of care that CMS measures.
Addressing this challenge requires improved coordination across health care settings and empowering Medicare patients to take a more active role in managing their own health. Previous Medicare care transitions projects have successfully reduced avoidable readmissions by focusing on the entire continuum of care, and including the patient.
As the Medicare Quality Improvement Organization for Missouri, Primaris will partner with important representatives of healthcare and general community settings to reduce avoidable readmissions. An avoidable readmission is one clinically related to a prior admission, if there was a reasonable expectation that it could have been prevented by:
In Fiscal Year 2012, inpatient prospective payments to hospitals will be reduced based on the dollar value of the hospital's percentage of preventable Medicare readmissions related to heart failure, acute myocardial infarction and pneumonia.
QIOs are tremendous allies in the effort to reduce avoidable hospital readmissions. A recent QIO Program initiative that involved 14 communities nationwide reduced admissions per 1,000 beneficiaries by 5.6%, compared with a 3.4% reduction in 52 peer communities
Learn from our video series on improving care transitions for Missouri's hospital patients:
Care coordination in Kansas City
Primaris is working with providers to coordinate care in Kansas City.