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You can't argue with the data: when state-based QIOs stepped in to coordinate 14 community-based interventions to manage care transitions, hospital readmissions among Medicare beneficiaries dropped more than twice as much as they did in comparison communities.

The QIOs' secret was a deep dive into local data, which uncovered a need for a skilled nursing facility network in one state, for example, and a dearth of home health services in another.

As these examples indicate, management of care transitions is not a one-size-fits-all proposition. Rethinking Readmissions: Patient-Centered Collaborations in Care Transition Management examines the data analytics driving the CMS Care Transitions Demonstration Project as well as some home-grown programs that are supporting patients' seamless transitions back into their communities.

Two-thirds of care transition management programs are self-developed, according to 2013 market data from the Healthcare Intelligence Network.

This 50-page resource begins with a review of results from the CMS Care Transitions demo by Alicia Goroski, MPH, senior project director for care transitions for the Colorado Foundation for Medical Care (CFMC), the national coordinator for the QIO effort. Ms. Goroski shares lessons learned from the 14 participating communities and details on program rollout to over 12 million Medicare beneficiaries in 400 communities across the country.

But even the most sophisticated root cause analysis must be accompanied by an organizational culture change that supports transitional care. At Regions Hospital, this transformation began with a subtle shift: replacing 'patient handoffs' with 'patient handovers.'

Rethinking Readmissions: Patient-Centered Collaborations in Care Transition Management reviews this change and other interventions that have helped to reduce Regions' readmission rates from over 11 percent in 2009 to 9.5 percent for all patients and achieve readmission rates for 2012 that are better than its expected results, as predicted by modeling outside of the organization.

This special report also features a look at Cullman Regional Medical Center's award-winning "Good to Go" recorded hospital discharge instructions, an intervention that has resulted in a 15 percent decline in readmission rates for patients who received recorded discharge instructions and a 58 percent increase in HCAPS satisfaction scores.

Joshua Brewster, director of care management at Regions Hospital, a HealthPartners hospital, and Cheryl Bailey, vice president of patient care services at Cullman Regional Medical Center, share the key features of their care transition management programs.

This report contains the following:

• Key findings in effective care transition management from the QIO pilot programs;
• How the QIOs are working with hospitals, nursing homes, home health agencies, hospice organizations, dialysis facilities and outpatient physicians to close care gaps;
• Patient and provider engagement strategies to improve transitions of care;
• Inside details from the QIO pilot program in northwest Denver, which saw special cause variation in the reduction of both readmissions and admissions;
• A look ahead to the QIO strategies being implemented by the rolled-out programs.
• The key factors that Regions has identified that place a patient onto its "hot list" for readmission risk;
• HealthPartners' handover process for patients at-risk of readmission;
• How HealthPartners meets the unique needs of patients with chronic obstructive pulmonary disease, congestive heart failure and behavioral healthcare needs at risk of readmission;
• The features of Cullman's "Good to Go" recorded instructions, from implementation guidelines to the program's expansion; and
• How internal analysis of the recorded discharge instructions has helped Cullman further refine its discharge process and identify patients in need of post-discharge support.

Table of Contents

• Community Collaborations That Improve Care Transitions
  • Community-Based Approach to Reducing Readmissions
  • Reexamining Readmissions Data
  • Intervention and Comparison Communities
  • Examining Hospitalizations Per 1,000 Beneficiaries
  • Final Overall Community Results
  • QIOs as Conveners and Supporters
  • Nursing Home Coalition
  • QIOs Move Ahead with Care Transition Improvement
• Shifting from ‘Handoffs’ to ‘Handovers’
  • Reviewing the Readmissions Numbers
  • Actual Versus Percentage of Readmissions
  • Changing Focus from Readmissions to Care Transitions
  • Medication Boot Camp
  • Closing Home Care Gaps
  • After-Visit Summaries
  • Care Plan Interventions
• Making Sure Newly Discharged Are ‘Good to Go’
  • ‘Good to Go’ Trial and Rollout
  • Recording Hospital Discharge Instructions
  • The Patient’s Reaction
  • Accountability and Compliance
  • Results from ‘Good to Go’
  • Challenges and Expansion
• Q&A: Ask the Experts
  • Defining Patient Contact
  • ‘Good to Go’ Beyond the Hospital
  • Process for Obtaining Real-Time Data
  • Engagement with ‘Good to Go’
  • Developing Risk Scores
  • Discharge Video Distribution and Engagement
  • Adherence Levels for Medication Boot Camp
  • Communication’s Role in Discharge Planning
  • Sharing Hospital Discharge Instructions
  • Interventions for Mental Health, CHF
  • Initial ‘Good to Go’ Pushback
  • Role of Medication Adherence in Care Transition Management
  • Health Coaching Interventions
  • Sample Care Transition Interventions
  • Community Factors That Drive Readmissions
  • Choosing Community Partners
  • Data Sharing Requirements within Partnerships
  • Patient Engagement and Education
  • Home Visits and Care Transitions
• Glossary
• For More Information
• About the Speakers