Care Transitions Management 2.0: Enterprising Approaches to Reduce Readmissions

Call it Care Transitions Management 2.0—innovative ideas ranging from recording patient discharge instructions to enlisting fire departments and pharmacists to conduct home visits and reconcile medications. To improve 30-day readmissions and avoid costly Medicare penalties, more than one-third of respondents to the 2015 Care Transitions Management survey—34 percent—have designed programs in this area, drawing inspiration from the Coleman Care Transitions Program®, Project BOOST®, Project RED, Guided Care® and other models.

Care Transitions Management 2.0: Enterprising Approaches to Reduce Readmissions
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2015 Healthcare Benchmarks: Care Transitions Management


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Colleen Swedberg

As groundwork for participation in CMS’s Bundled Payments for Care Improvement initiative, St. Vincent's Health Partners (SVHP) formed a cross-functional cross-boundary Transitions Leadership Group to map what happens to patients moving along their care journeys, explains Colleen Swedberg, MSN, RN, CNL, director for care coordination and integration. In this audio interview, Ms. Swedberg describes the structure and goals of the Transitions Leadership Group and some tools and protocols it developed to set standards for any post-acute provider wishing to join the SVHP network.


Related blog posts:

Infographic: 2015 Post-Acute Care Challenge: How to Foster Warm Handoffs

Post-Acute Care Payment Bundles: Catalyst for Clinical Redesign, Improved Care Transitions

5 Drivers of San Francisco Care Transitions ‘Clearinghouse’

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2015 Healthcare Benchmarks: Care Transitions Management

More information on this topic can be found in: 2015 Healthcare Benchmarks: Care Transitions Management, HIN's fourth annual analysis of these cross-continuum initiatives, examines programs, models, protocols and results associated with movement of patients from one care site to another, including the impact of care transitions management on quality metrics and the delivery of value-based care.