Care Transitions

Background

The process of moving patients from hospitals to other care settings is becoming increasingly problematic. Nearly 1 in 5 Medicare beneficiaries are re-hospitalized within 30 days, and up to three-fourths of these readmissions may be preventable. This situation can be changed.

• Re-hospitalization rates vary substantially among geographic locations, suggesting opportunities for improvement in the areas with higher rates.
• Recent work suggests that interventions targeting comprehensive transitional care from the hospital to the community can reduce readmission rates by approximately one third.
• Improved health care processes at and after discharge correlate with substantial reductions in early re-hospitalization for certain conditions, such as heart failure.
• QIOs have helped providers to analyze data, and to identify and address gaps in care, such as transitions and end-of-life care planning.
  

Overview
Background
Provider Benefits
Patient Benefits
Resources and Tools

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