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Care Transitions
The process by which patients move from hospitals to other care settings is increasingly problematic as hospitals shorten lengths of stay and as care becomes more fragmented. Medicare patients report greater dissatisfaction related to discharges than to any other aspect of care that CMS measures.
To address this issue, SDFMC is working to measurably improve the quality of care for Medicare beneficiaries who transition among care settings through a comprehensive community effort. These efforts to "Prevent Avoidable Readmissions through Transitions" have a common goal -- to reduce readmissions following hospitalization by 20 percent over three years and to yield sustainable and replicable strategies to achieve high-value health care for sick and disabled Medicare beneficiaries.
Although South Dakota currently experiences low rates of readmissions for Medicare patients, CMS has funded SDFMC to work with selected communities to encourage their efforts to improve care transitions. SDFMC plans to assist hospitals and communities on three levels in their efforts to improve care transitions:
Assist eligible communities in applying for participation in a Formal Care Transitions Program, e.g., Community-Based Care Transitions Program (CCTP)Provide extensive assistance to at least one specific community to implement an improvement plan that coordinates hospital and community-based systems of careFacilitate a statewide care transitions Learning and Action Network (LAN)
By assisting providers within the chosen communities to select evidenced-based interventions associated with the identified drivers of readmission, SDFMC will encourage interventions that result in reduced readmissions and improved transitions. These could include:
Hospital and community interventions to improve processes of care at a system level—interventions which may include redesigning discharge protocols, adopting information technology solutions, or creating a new protocol for transferring hospital patients to skilled nursing facilities,Interventions that impact hospital readmission for specific diseases or conditions, such as acute myocardial infarction, congestive heart failure (CHF) and pneumonia—these may include, for example, CHF disease management programs or the Care Transitions Intervention (providing patients with a “transition coach” and education in self-management skills)
Interventions that address community-specific reasons for hospital readmission—interventions may include creating services, such as palliative care, that can decrease the readmission rate simply because patients previously had no alternative to hospitalization.
This is a new and exciting area for SDFMC participation. For more information, please contact:
Sue Johannsen, PAC GNP, 605-336-3505, sjohannsen@sdqio.sdps.org.
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All information on this site is provided as a public service only and should not be relied upon as medical or legal advice. Some of the information included in this site was obtained through work performed under a contract with the Centers for Medicare & Medicaid Services, Department of Health and Human Services. SDFMC shall not be held liable for any damages arising from the use of or reliance upon information supplied herein. Any links to other organizations contained on this site are for informational purposes only and do not imply endorsement by SDFMC.
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