Community-based care transitions initiatives to reduce hospital readmissions


As Medicare’s Quality Improvement Organization (QIO) for Oregon, Acumentra Health convened communities between 2011 and 2014 to facilitate communication across care settings and improvement efforts aimed at reducing avoidable hospital admissions.

We engaged providers, patients, and stakeholders, using activities shaped by community needs and planned to align and coordinate with other ongoing projects. Our goal was sustainable, community-led approaches for helping patients avoid rehospitalization.

This project was part of a national effort by the Medicare QIO Program to coordinate community-based, cross-setting work that would 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. Our interventions in Oregon drew on tools tested during a successful 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.

Activities included the statewide No Place Like Home Campaign as well as targeted support for individual communities. Acumentra Health also supported applications for funding under the Community-based Care Transitions Program.