“The global re-hospitalization rate of a community reflects the cumulative quality of care provided across diverse settings and providers,” say the IPRO Care Transitions Team quality improvement professionals in a new article published in the May/June 2011 edition of Patient Safety & Quality Healthcare. Noting that nearly 20% of all hospitalized Medicare beneficiaries are re-admitted to hospitals within 30 days of discharge, the authors describe a number of initiatives undertaken as part of a Centers for Medicare & Medicaid Services three-year, IPRO-led Care Transitions Quality Improvement Initiative involving five contiguous counties in upstate New York. The article describes the work of Ellis Hospital (Schenectady, NY) in developing a community-wide effort to develop systems of care management for patients with heart failure; the use of interdisciplinary teams to improve patient-focused communications at Northeast Health Systems Albany Memorial Hospital (Albany, NY) and Samaritan Hospital (Troy, NY); cross-setting medication reconciliation and post acute care follow-up after discharge at Seton Health/St. Mary’s Hospital (Troy, NY); improved communications between hospitalists and primary care physicians regarding high-risk heart failure patients at Saratoga Hospital (Saratoga, NY) and the use of care transition coaches to foster patient/caregiver activation and self-management post hospital discharge from Glens Falls Hospital (Glens Falls, NY). Links to “Understanding Care Transitions as a Patient Safety Issue,” in the May/June 2011 edition of Patient Safety & Quality Healthcare are available from the IPRO Care Transitions website (linked from www.ipro.org). The article was written by the IPRO Care Transitions Team.