Care Coordination Coalition

Visit the No Place Like Home website to join the Campaign and access free resources.

Community initiatives to reduce hospital readmissions

As Medicare’s Quality Improvement Organization (QIO) for Oregon, Acumentra Health convenes the Care Coordination Coalition (CCC) to facilitate communication and joint improvement activities aimed at reducing avoidable hospital admissions. The CCC coordinates activities within Oregon communities, engaging providers, patients, and stakeholders through a learning and action network (LAN) approach. Coalition activities are shaped by community needs and planned to align and coordinate with other ongoing projects, with the ultimate goal of developing a sustainable, community-led approach for improving care.

The CCC is part of a national effort by the Medicare QIO Program to coordinate community-based, cross-setting work to integrate patient care and reduce unnecessary hospital admissions. Nationally, nearly 1 in 5 Medicare patients discharged from a hospital is readmitted for hospital care within 30 days; readmissions are reported to have cost Medicare $26 billion over 10 years. The CCC has access to tools tested during a 13-state QIO pilot program, including approaches based on effective communication, coordination between settings, and activation of patients and caregivers to handle appropriate issues without hospital visits.

CMS project overview (PDF)

CCTP application support

Acumentra Health assisted community organizations in 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
CCTP program page

Care Transitions resources

National Coordinating Center for the Integrating Care for Populations and Communities Aim
Comprehensive support for communities developing transitional care programs, including a toolkit of analysis and intervention materials, recorded webinars, and model documents created during the pilot program. The website is hosted by the Colorado QIO (CFMC), which led the pilot program and coordinates 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)

Institute for Healthcare Improvement

Resources: Improving Transitions in Care

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.