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:
- Providing quality care during the patient's first hospital stay
- Adequately planning the patient's discharge
- Improving coordination between inpatient and outpatient care teams
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.
Primaris' goals:
- Ensure a community-wide impact on improving care transition for Medicare patients
- Drive sustainable changes in care from a community perspective
- Assist healthcare communities with root-cause analysis, evidence-based interventions for care transitions and applying to the national Community Based Care Transition Program
- Create Learning and Action Networks for Care Transitions (more information to come)
To join the effort to improve care transitions in Missouri, or to get more information about this campaign, please contact Primaris Senior Program Manager Anne Carpenter by email or phone 1-800-735-6776.
Care Transitions Project - An Overview
