Patricia Simino Boyce
IPRO is honoring a select group of health care providers in the Upper Capital Region who have signed on to a three-year project aimed at making dramatic improvements in care transitions and reducing avoidable readmissions to hospitals. The providers volunteering to participate in the high-profile Care Transitions Project include hospitals, nursing homes, home health agencies, physicians’ offices, rehab centers, dialysis centers and hospices located in the counties of Warren, Washington, Rensselaer, Schenectady and Saratoga. Nationally, almost 20% of Medicare beneficiaries are readmitted to hospitals within 30 days of discharge, while the vast majority of these readmissions may be preventable. Unplanned re-hospitalizations accounted for an estimated $17.4 billion in Medicare spending in 2004.
As the not-for-profit Medicare-funded Quality Improvement Organization (QIO) for New York, IPRO works with providers across the state to improve performance on a series of inpatient and outpatient quality measures. The Care Transitions Project takes an innovative, community-based approach that emphasizes collaboration across settings and among distinct provider groups in order to better coordinate care for Medicare beneficiaries with chronic illnesses. IPRO is one of fourteen QIOs nationally selected by the Centers for Medicare & Medicaid Services (CMS) for this initiative.
“We congratulate those Capital Region providers who are joining together to make dramatic improvements in care continuity, with the goal of reducing costly and often unnecessary readmissions to hospitals,” according to Clare Bradley, MD, MPH, Chief Medical Officer at IPRO. “To do this, we need to do a better job of identifying high-risk patients before discharge and implementing post-discharge care plans that address contingencies. We also need to make sure reliable transfer information gets shared across settings.”
Health care providers participating in this initiative are establishing systems to ensure reliable transfer of patient information across settings and are working to increase patient/caregiver satisfaction by keeping patients and their family members better informed about their conditions and medications.
In addition to working with health care providers and community leaders, IPRO is helping to empower the community by providing tools and information to help patients better manage their health care, keep track of their medications and support follow-up care post discharge from the hospital. The Personal Health Record (PHR) is an example of one of the helpful tools supported within this project. The PHR is a booklet for people to record, store and share all of their essential health care information with their health care providers.
Upper Capital Region providers and stakeholders currently participating in the project include:
- Adirondack Tri-County Nursing & Rehabilitation Center
- Baptist Health Nursing and Rehabilitation Center
- Capital Care Medical Group
- Capital District Physicians Health Plan
- Community Hospice
- Ellis Hospital
- Fort Hudson Nursing Center
- Glens Falls Hospital
- H & L Rubin Dialysis Centers
- High Peaks Hospice and Palliative Care, Inc.
- Hoosick Falls Health Center
- Hudson Headwaters Health Network
- Kingsway Arms Nursing Center
- MVP Health Care
- Pleasant Valley
- Resurrection Nursing Home
- Saratoga Care Nursing Home
- Saratoga County Public Health
- Saratoga Hospital
- Seton Health/St. Mary’s Hospital
- Seton Health at Schuyler Ridge
- Seton Home Health Care
- The Avenue/Capital Living and Rehabilitation Centres
- The Dutch Manor/Capital Living and Rehabilitation Centres
- The Springs/Capital Living and Rehabilitation Centres
- The Stanton/Capital Living and Rehabilitation Centres
- Van Rensselaer Manor Nursing Facility
- VNSA of Schenectady and Saratoga
- Warren County Public Health
- Washington County Public Health
- Wesley Health Care Center Inc.
- The Orchard Nursing and Rehabilitation Centre
- Glens Falls Dialysis Center
- Ellis Residential & Rehab Center
- Healthcare Information Xchange of New York
This material was prepared by IPRO, the Medicare Quality Improvement Organization for New York State, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy. 9SOW-NY-THM7.2-09-13