4 Broad Strategies to Improve Transitions of Care

The success of Medicare Quality Improvement Organization-led initiatives in reducing readmissions is due in part to community engagement and coordinating care between providers, according to a study in the Journal of the American Medical Association.

The study found that 14 communities that implemented quality improvement initiatives led by Medicare Quality Improvement Organizations reduced readmissions and hospitalizations by nearly double the reductions that communities without these initiatives achieved. The 14 communities reduced readmissions 5.7 percent, while the communities without the Quality Improvement Organizations reduced readmissions by 2.06 percent.


The American Health Quality Association, which represents Quality Improvement Organizations, issued a news release that includes strategies these organizations used to reduce readmissions in the 14 communities. The strategies generally fit one of the following four categories, according to the release:

•    Developing effective community coalitions. Community coalitions include hospitals, nursing facilities, home care, hospice agencies, physicians and local agencies that work together to help meet social service needs that affect patients' wellness.
•    Standardizing transition processes. Standardizing the transition processes across all local healthcare settings.
•    Efficiently transferring clinical information. Sharing patients' clinical information among providers efficiently and effectively.
•    Actively engaging patients. Patients and family members can be engaged in their transitions by keeping a personal record, knowing warning signs for health problems, ensuring they receive the right medications and participating in the appropriate follow-up care.

More Articles on Transitions of Care:

Study: Nearly 40% of Post-Discharge Acute-Care Encounters at Hospitals Are ED Visits
Study: Medicare Readmissions Decreased More in Areas With Quality Improvement Initiatives

Patient Navigators Play Key Role in Improving Quality, Lowering Costs

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