Care Coordination Coalition

Integrating Care for Populations and Communities

Community initiatives

The Medicare Quality Improvement Organization (QIO) Program brings an exciting new dimension to QIO assistance in 2011: coordination of a community-wide cross-setting effort to integrate patient care across settings, with a target of reducing unnecessary hospital admissions by 20% over three years. Nationally, nearly 20% of Medicare patients discharged from hospitals are readmitted for hospital care within 30 days, and readmissions are reported to cost Medicare $26 billion over 10 years. Communities in 13 states recently completed a QIO pilot program, developing many tools for reducing readmission rates through effective communication, coordination between settings, and activation of patients and caregivers to handle appropriate issues without hospital visits.

As Medicare's QIO for Oregon, Acumentra Health will convene the Care Coordination Coalition (CCC) to facilitate communication and joint improvement activities between hospitals and other care providers. The CCC will coordinate activities with Oregon communities between August 2011 and July 2014, engaging providers, patients, and stakeholders through a learning and action network (LAN) approach. Coalition activities will be shaped by the needs and circumstances within each community and will align and coordinate with other ongoing projects.

CMS project overview (PDF)

CCTP application support

Acumentra Health will also assist community organizations that are applying for project funding under the federal Community-based Care Transitions Program (CCTP), a demonstration project that aims to reduce hospital readmissions, test sustainable funding streams for care transition services, maintain or improve quality of care, and document measureable savings to the Medicare program.

CCTP preparation resources

Care Transitions resources

National Coordinating Center,
Integrating Care for Populations and Communities

Oregon communities developing transitional care programs can find comprehensive support online in a toolkit of analysis and intervention materials, recorded webinars, and model documents created as part of the 14-state pilot program. The website is hosted by the Colorado QIO (CFMC), which led the pilot program and is the National Coordination Center for the current national project.

Toolkit (CFMC)
Care transitions resources (CFMC)

Home Health Quality Improvement National Campaign

Access to tools requires free registration as a campaign participant, other provider, or campaign supporter; see links at top of BPIP page.

Best Practice Intervention Package:
Introduction and Fundamentals of Reducing Avoidable Hospitalizations (January 2010)

Care Transitions Search Widget

This search widget is optimized to look for high-quality content on improving care transitions and patient safety. Enter a search term and click the "Search" button. The results will appear with tabs at the top to help you filter your results for content on specific issues as they relate to your search. The widget was developed by Dr. Joanne Lynn and colleagues at Altarum Institute. For more information and free web code, visit MediCaring.org.

Loading


Last updated December 9, 2011