IPRO Care Transitions Team Documents Success

IPRO authors have written another article showing significant reductions in hospital readmission rates following implementation of a community-based care transitions program. The article profiles an Albany NY-area effort involving one acute care hospital, 28 skilled nursing facilities, a home health agency and a hospice provider. The authors document significant reductions in all-cause 30-day readmission rates from post-acute settings during 2011-2014, as well as significant improvements in rates of satisfaction among hospitalized patients. They argue that financial incentives and care coordination provisions included in the Affordable Care Act “compelled providers who were once competitors to look at each other as partners-in-care.” The article focuses on concerted efforts to improve provider communications, using cross-setting contact lists, standardized transfer-of-information forms, better clinician-to-clinician dialogue, electronic health records, nursing facilities capabilities analysis and information-sharing between community-based clinicians and the hospital emergency department. The article “New York State Coalition Improves Communication for Care Transitions,” by Fred Ratto Jr., and colleagues, appears in Patient Safety & Quality Healthcare (May/June 2015), which is available at www.psqh.com