By Kathy Greenlee, Assistant Secretary for Aging and Administrator of ACL
This week the Journal of the American Medical Association published the article “Association between quality improvement for care transitions in communities and re-hospitalizations among Medicare beneficiaries,” by Dr. Jane Brock and other members of the Care Transitions Quality Improvement Organization (QIO) Support Contract team. The findings in the article validate a community-based approach to improve the quality of care as people transition between doctor’s offices or clinics to the hospital, and between the hospital and home.
The article describes how the 14 QIOs working on the Care Transitions project improved community-wide health by reducing the percent of patients hospitalized in a community. Between 2008 and 2011, the QIOs used community organizing tools, put evidence-based care transitions interventions in place, and collaborated with community partners across the continuum of health and long-term services and supports.
Collaborators in 14 communities across the U.S. included:
- hospitals
- skilled nursing facilities
- home health agencies
- Area Agencies on Aging
- local social services providers
- hospice facilities, and
- primary care practices
Partners contributed time and resources, implemented interventions and monitored their effects. Hospitalization and re-hospitalization rates dropped as a result, showing that when health care providers and communities come together as a team, they can improve the health and quality of life of patients and their caregivers.
By using data analysis and community organizing tactics, collaborators were able to tailor strategies and interventions and track results that ultimately led to success. This approach transforms the relationships between hospitals and primary care, between doctors and social workers and between medical and long-term services and supports, and unites the science of quality improvement efforts with the momentum and diversity of community coalitions.
The work started by these 14 communities now continues across all U.S. states and territories (led by all 53 QIOs). Two-hundred-and-twenty communities have publicly committed to reducing hospital re-admissions by 20 percent.
I encourage you to take a look at the work that was the foundation for the JAMA article and become a part of the continued partnerships to improve care transitions and reduce re-admissions. More information about the article can be found at http://www.altarum.org/QIOpaper 
. Specific information about how the Care Transitions project lives on as the national Integrating Care for Populations and Communities project is available at http://www.cfmc.org/integratingcare .
To learn more about how our partners at the Centers for Medicare & Medicaid Services engage QIOs, an independent network of quality improvement experts in 53 states and territories across the country, to transform care for millions of Medicare beneficiaries, visit http://go.cms.gov/qios.
CMS adds 35 communities to the Community-based Care Transitions Program (CCTP)
In other progress, last week CMS announced 35 new communities will participate in the Community-based Care Transition Program. Aging and disability networks are integral partners under this program. They provide trained staff members who work with beneficiaries to safely transition home after a hospital stay. They track progress and measure the results of strategies put in place. They help lead the conversation and shape the next steps taken by all the partners that have committed to improving care.
For more information about all of the CCTP sites and their collaborative efforts under the Partnership for Patients, visit http://partnershipforpatients.cms.gov/.