Community-based care transitions occur when a patient moves from one health care provider or setting to another, or from a health care provider to home. Effective care transitions are important for optimizing patient health and for avoiding unnecessary utilization of hospital services and related services. As CMS has noted:
Nearly one in five Medicare patients discharged from a hospital—approximately 2.6 million seniors—is readmitted within 30 days, at a cost of over $26 billion every year. Hospitals have traditionally served as the focal point of efforts to reduce readmissions by focusing on those components that they are directly responsible for, including the quality of care during the hospitalization and the discharge planning process. However, it is clear that there are multiple factors along the care continuum that impact readmissions, and identifying the key drivers of readmissions for a hospital and its downstream providers is the first step towards implementing the appropriate interventions necessary for reducing readmissions.
Community Health Solutions works at the community level to support the development of community-based care transition models. We help hospitals, health systems, and their community partners:
- Define objectives for optimizing care transition for specific groups of at-risk patients;
- Design care transition models that meet defined needs utilizing evidence-based practices and community partnerships;
- Build organizational capacity for implementing care transitions; and
- Execute for improved quality and outcomes.
We provide these supports through a combination of research, advice, technical assistance, training, and performance support. When multiple teams or organizations are involved, we offer our Learning Collaborative solution to optimize organizational learning and execution.