The Care Transitions Project of Whatcom County is aimed at eliminating unnecessary readmissions to St. Joseph Hospital. Studies across the country have demonstrated that there are potential gaps in communication and coordination when patients move from one setting or aspect of care to another resulting in patient risk and increased costs. The aim of this project is to bridge those gaps and enable safer and more effective transitions.

The Centers for Medicare & Medicaid Services (CMS) has contracted with Qualis Health (Washington’s quality improvement organization) to engage community partners including healthcare providers, patients, and families, in the Care Transitions Project through 2011.

GoalsThe goals of the project are to:

• Connect providers throughout the healthcare system in Whatcom County to enable safe and effective transition of patients.
• Eliminate unnecessary hospital readmissions to St. Joseph Hospital.
• Enable Whatcom County patients and their families to participate fully in their health and healthcare, particularly when leaving the hospital.

StrategiesTo accomplish the goals, the participating partners in the project will:

• Engage healthcare providers to ensure optimal coordination, communication and information exchange around the needs of each patient and family, particularly when patients are leaving the hospital. Activities include identifying patients at highest risk, using the CMS CARE tool, and implementing the teach-back technique.
• Implement use of care transition coaches and coaching protocols to help patients self-manage their care.
• Expand use of Shared Care Plan Personal Health Record among Whatcom County residents.
• Activate strategic partnerships that engage key healthcare, business, nonprofit, and government entities within the community in the Care Transitions Project.

Download the printer friendly Stepping Stones Fact Sheet

View the list of project sponsors

Centers for Medicare & Medicaid Services (CMS) Care Transitions PrioritiesCMS has made care transitions a priority and has asked Quality Improvement Organizations (QIOs) across the country to implement care transitions work in 14 communities. CMS states that “The Care Transitions Theme focuses on improving coordination across the continuum of care. In particular, Quality Improvement Organizations (QIOs) will promote seamless transitions from the hospital to home, skilled nursing care, or home health care.

QIOs will work to reduce unnecessary readmissions to hospitals that may increase risk or harm to patients and cost to Medicare. CMS will look to QIOs to implement projects that effect process improvements to address issues in medication management, post-discharge follow-up, and plans of care for patients who move across healthcare settings.

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. This situation can be changed. In general, re-hospitalization rates and health care utilization vary substantially across geographic locations, suggesting opportunities for improvement in areas with higher observed rates. Improved health care processes at and after discharge correlate with substantial reductions in early re-hospitalization for particular conditions, such as heart failure. In addition, prior and ongoing QIO work has assisted providers in analyzing data and in identifying and addressing gaps in care in areas such as transitions and end-of-life planning and care.”