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Project Targets Unnecessary Hospital Readmissions

June 9, 2009:

From now until the summer of 2011, 14 selected communities have been chosen to participate in the pilot Care Transitions Project to determine the reasons for unnecessary hospital readmissions and eliminate them. Data have demonstrated that one in five patients discharged from a hospital with be readmitted within the month, and as many as 75 percent of these admissions could be prevented.

The pilot project aims to improve health care processes so patients, care givers, and providers all have the necessary resources to prevent patients from returning to the hospital. It is speculated that promoting seamless transitions from the hospital to home, skilled nursing care, or home health care can lower hospital readmissions and help realize high-quality health care.

Using the community-level model, specific strategies can be developed that direct efforts at the underlying problems in a particular community that result in hospital readmissions.

The following communities were chosen to participate in the project:

  • Providence, Rhode Island
  • Upper Capitol Region, New York
  • Western Pennsylvania
  • Southwestern New Jersey
  • Metro Atlanta East, Georgia
  • Miami, Florida
  • Tuscaloosa, Alabama
  • Evansville, Indiana
  • Greater Lansing Area, Michigan
  • Omaha, Nebraska.
  • Baton Rouge, Louisiana.
  • North West Denver, Colorado
  • Harlingen, Texas
  • Whatcom County, Washington

Each community is led by a state quality improvement organization (QIO) that is required to work with participants to implement the following:

  • Hospital and community systemwide interventions
  • Interventions targeting specific diseases/conditions
  • Interventions targeting specific reasons for admission

Participating QIOs include:

  • Quality Partners of Rhode Island
  • IPRO Inc. (New York)
  • Quality Insights of Pennsylvania
  • Healthcare Quality Strategies Inc. (New Jersey)
  • Georgia Medical Care Foundation Inc.
  • FMQAI (Florida)
  • AQAF (Alabama)
  • Health Care Excel (Indiana)
  • MPRO (Michigan)
  • CIMRO of Nebraska
  • Louisiana Health Care Review
  • Colorado Foundation for Medical Care
  • TMF Health Quality Institute (Texas) and
  • Qualis Health (Washington)

Kristin Bentley, CPC
Clinical/Technical Editor


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