Care Transitions

Increasingly, there is evidence of serious deficiencies in quality of care for Medicare beneficiaries undergoing transitions across sites of care. Particularly vulnerable are those with multiple chronic illnesses and complex care needs who experience care across different health provider settings.

Studies have shown that transitions can jeopardize patient safety and quality of care as a result of incomplete and/or inaccurate transfer of information, medication discrepancies and the lack of appropriate post-acute care. These deficiencies lead to adverse medication events, exacerbation of chronic illness and the inability of patients and families to recognize and react to signs of acute illness. All these factors contribute to the high 30-day re-hospitalization rates of Medicare beneficiaries: 17.6% nationally (MedPAC) and 12.05% in Georgia.

In order to address this deficiency, GMCF, under the Care Transitions theme, will champion community care transition interventions to measurably improve post-acute care coordination and reduce rehospitalization rates in a targeted Georgia community. The interventions may depend on changes in processes of care that engage more than one provider (including hospitals, home health agencies, nursing homes, dialysis centers, and physician offices) as well as patients, families and stakeholders.

Overview
Background
Provider Benefits
Patient Benefits
Resources and Tools