Care transitions refer to movement of patients from one health care provider or setting to another. Seamless care transitions require thoughtful collaboration among hospitals, community-based organizations, long-term and post-acute care providers, patient caregivers, and patients themselves.
Organizations that work with Hospitals
Safe, effective, and efficient care transitions and reduced risk of potentially preventable readmissions require cooperation among providers of medical services, social services, and support services in the community and in long-term care facilities. Organizations working with hospitals to improve care transitions include:
- Clinicians practicing in the ambulatory setting
- Home care agencies
- Community service providers
- Post-acute facilities (such as skilled nursing facilities, rehabilitation, and assisted living)
While much of the readmissions discussion addresses the transition from acute hospital to home or other post-acute setting, the principles and resources are relevant for all transitions from one health care setting to another.
Quality Improvement Organizations (QIOs)
QIOs have aligned their efforts with the Partnership for Patients. They’re implementing evidence-based ways to improve care at the point of the transition which helps reduce unnecessary hospital readmissions. They have also facilitated communication between multiple providers who treat patients with chronic illnesses and coached patients in ways to take a more active role in managing their health care.
QIOs in all 50 states are now convening communities of providers and stakeholders to improve care for patients as they transition between care settings. QIOs can assist individual health care and social services providers to:
- Connect with partners in their community or form a community coalition;
- Conduct a comprehensive “root cause analysis,” using Medicare data, to determine the major causes of readmissions in their community;
- Select and implement evidence-based care transitions interventions and solutions tailored to the unique readmission drivers.
The Partnership encourages and supports patients and families to be active participants in their care and decision-making at whatever level they feel comfortable. Patients and families are sharing their patient stories and participating on boards, workgroups, and advisory councils in hospitals and community-based organizations across the country.