What is “Do Your PART?”

The “Do Your PART” campaign, Preventing Avoidable Readmissions through Transitions, uses a systematic, comprehensive approach to a multi-faceted problem. Because reducing readmissions requires better information transfer between health care providers and patients, as well as increased patient activation and improved workflow processes, there are opportunities for patients, caregivers and families to all “do their part.” Creating seamless transitions involves many players in numerous settings.

What can you do?
• Identify why people are being readmitted to the hospital – do a Root Cause Analysis
• Implement, track and measure interventions to reduce 30-day readmissions
• Engage patients and families to be more involved in their care

Reducing Readmissions

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. Alliant | GMCF is "doing its PART" to measurably improve the quality of care for Medicare beneficiaries who transition among care settings through a comprehensive community effort. These efforts to "Prevent Avoidable Readmissions through Transitions" have a common goal -- to reduce readmissions following hospitalization by 20 percent over three years and to yield sustainable and replicable strategies to achieve high-value health care for sick and disabled Medicare beneficiaries.

Alliant | GMCF is a ready resource for taking action on providers’ commitment to the Partnership for Patients and for meeting the requirements of Value Based Purchasing. We are a knowledgeable, credible and trusted partner.

Georgia Hospital Association (GHA) Care Transitions Special Interest Group

The vision of the Transitions of Care special interest group is that all patients admitted to Georgia hospitals will receive the necessary tools and information that will prepare them for care after the hospital stay. This community-wide organization is sponsored by the Partnership for Health and Accountability of the Georgia Hospital Association. The members of the special interest group come from a wide base of providers within the state of Georgia. Website

Care Transitions Learning and Action Network, in partnership with the GHA Hospital Engagement Network (HEN)

A Learning and Action Network (LAN) brings provider communities together around a common agenda, improving care transitions and reducing hospital readmissions. The "all teach, all learn" collaborative model allows participants to hear from experts and peers who are facing the same challenges. The goal of the LAN is to promote community-wide adoption of evidence-based best practices to reduce hospital readmissions.

On the first Wednesday of each month from 11 a.m. to noon, learning sessions are conducted via webinar by Alliant | GMCF and GHA. Materials are located on the GHA Reducing Readmissions website:

Georgia Hospital Association (GHA) webinars and resource materials

All providers are welcome to join the learning sessions.

For more information about participating in the LAN, contact Mary Perloe mary.perloe@gmcf.org 678-527-3425

INTERACT (Interventions to Reduce Acute Care Transfers) is a quality improvement program that focuses on the management fo acute change in resident condition. It includes clinical and educational tools and strategies for use in every day practice in long-term care facilities. The goal is to improve care and reduce the frequency of potentially avoidable transfers to the acute hospital. Such transfers can result in numerous complications of hospitalization, and billions of dollars in unnecessary health care expenditures.

The Centers for Medicare and Medicaid Services (CMS) announced funding opportunities for acute-care hospitals with high readmission rates that partner with community based organizations (CBOs) or CBOs that provide care transition services to improve a patient’s transition from a hospital to another setting, such as a long-term care facility or the patient’s home. Created by Section 3026 of the Affordable Care Act, the Community-Based Care Transition Program (CCTP) provides funding to test models for improving care transitions for high risk Medicare patients by using services to manage patients’ transitions effectively. Participants will use process and outcome measures to report on their results.

The parish nurse is a key resource in health care within their church family community. Like any family, the faith-based nurse supports the needs of the church family in troubling times such as a hospitalization. The faith-based nurse can provide both the physical and spiritual reassurance to patients that they have the ability to be proactive in their care.

These licensed, registered nurses combine their medical knowledge with spiritual care. Parish nurses help members of the faith community to maintain or regain wholeness in body, mind and spirit. Faith Community Nursing (FCN) is recognized as a specialty nursing practice.

The Care Transitions Search Widget is a free service that you can install on your own site to help your users find high-quality content related to quality improvement for healthcare systems. You can see a list of partner sites that are using the widget.

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Do Your PART is a campaign led by Alliant | GMCF and the Georgia Hospital Association. This website is supported by Alliant | GMCF, the Medicare Quality Improvement Organization for Georgia, under a contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication number: 10SOW-GA-ICPC-11-42