The Centers for Medicare & Medicaid Services (CMS), Washington, reports that 14 communities around the nation have been chosen for the agency’s Care Transitions Project, seeking to eliminate unnecessary hospital readmissions.

“Our data show that nearly one in five patients who leave the hospital today will be re-admitted within the next month, and that more than three-quarters of these re-admissions are potentially preventable,” says CMS Acting Administrator Charlene Frizzera. “This situation can be changed by approaching health care quality from a community-wide perspective, and focusing on how all of the members of an area’s health care team can better work together in the best interests of their shared patient population.”

The project’s goal is to improve health care processes so that patients, their caregivers, and their entire team of providers have what they need to keep patients from returning to the hospital for ongoing care needs. By promoting seamless transitions from the hospital to home, skilled nursing care, or home health care, this communitywide approach seeks to reduce hospital readmissions and to yield sustainable and replicable strategies that achieve high-value health care for Medicare beneficiaries

Barry M. Straube, MD, chief medical officer for CMS and its Office of Clinical Standards and Quality director, says the agency is eschewing a
one-size-fits-all solution, and Care Transitions teams will design customized solutions that address the underlying local drivers of re-admissions.

Communities in these regions have been chosen to participate in the project: Providence, RI; Upper Capitol Region, NY; western Pennsylvania; southwestern New Jersey; Metro Atlanta East, Ga; Miami; Tuscaloosa, Ala; Evansville, Ind; Greater Lansing Area, Mich; Omaha, Neb; Baton Rouge, La; North West Denver, Colo; Harlingen, Tex; and Whatcom County, Wash.

Each of the Care Transitions communities is led by a state Quality Improvement Organization (QIO). QIOs work throughout the country as part of CMS’s quality program to help health care providers, consumers, and stakeholder groups to refine care delivery systems to make sure all Medicare beneficiaries get the high-quality, high-value health care they deserve. Each QIO in the project is required to work with partners to implement the following:

-hospital and community system-wide interventions;
-interventions that target specific diseases or conditions; and
-interventions that target specific reasons for admission.

CMS will monitor the success of the project by watching the rates at which patients in these communities return to the hospital. Re-admission rates for hospitals have been tracked by CMS for some time, and will be available to consumers later this year through the Hospital Compare Web site at http://www.hospitalcompare.hhs.gov.

The Care Transitions Project will continue in all 14 communities through summer 2011. For more information about the Care Transitions Project, visit http://www.cfmc.org/caretransitions/. To learn more about the work that QIOs are doing across the country, visit http://www.cms.hhs.gov/qualityimprovementorgs.

[Source: CMS]