NDHCRI - Care Transitions

CARE TRANSITIONS

The process by which patients move from hospitals to other care settings is increasingly problematic as hospitals shorten lengths of stay and as care becomes more fragmented. Medicare patients report greater dissatisfaction related to discharges than to any other aspect of care that CMS measures.

In general, rehospitalization rates and health care utilization varies from community to community as well as diagnosis suggesting opportunities for improvement in areas with higher observed rates. The Medicare Payment Advisory Commission estimates that up to 76% of readmissions within 30 days of discharge may be preventable.

North Dakota Health Care Review, Inc. (NDHCRI) is poised to support hospitals and communities improve care transitions on three levels by:

Assisting eligible communities in applying for participation in a Formal Care Transitions Program, e.g., Community-Based Care Transitions Program (CCTP)
Providing extensive assistance to one specific community to implement an improvement plan that coordinates hospital and community-based systems of care
Facilitating a statewide care transitions Learning and Action Network (LAN)

NDHCRI will assist providers within communities to select evidenced-based interventions associated with the identified drivers of readmission. Interventions that result in reduced readmissions and improved transitions in care may be:

Hospital and community interventions to improve processes of care at a system level—interventions which may include redesigning discharge protocols, adopting information technology solutions, or creating a new protocol for transferring hospital patients to skilled nursing facilities
Interventions that impact hospital readmission for specific diseases or conditions, such as acute myocardial infarction, congestive heart failure (CHF) and pneumonia—these may include, for example, CHF disease management programs or the Care Transitions Intervention (providing patients with a “transition coach” and education in self-management skills)
Interventions that address community-specific reasons for hospital readmission—interventions may include creating services, such as palliative care, that can decrease the readmission rate simply because patients previously had no alternative to hospitalization

For more information, please contact Sally May, RN, BSN, Quality Improvement Specialist, at NDHCRI.

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