Care Transitions Toolkit
Comprehensive management of post-acute care transitions — hospital to home, hospital to nursing home and even ER to home — has been demonstrated to curb avoidable healthcare utilization and close gaps in care, while improving the patient experience and provider reimbursement levels.
To promote these initiatives, CMS is putting $500 million behind its Community-Based Care Transitions Program (CCTP) demonstration. CCTP is designed to help hospitals improve Medicare patient handoffs between care sites, reduce hospital readmissions, test sustainable funding streams for care transition services and document measureable savings to the Medicare program.
The Care Transitions Toolkit examines current and emerging trends in care transition management, providing actionable data and case studies from industry thought leaders on key elements of their care transition programs.
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For example, Summa Health System rallied 40 independent skilled nursing facilities (SNF) to form a network that has elevated its hospital-to-SNF transfers of care, reducing readmissions and length of stay for Summa patients released to SNFs in the process.
And by taking a multidisciplinary approach to providing post-discharge support, HealthCare Partners Medical Group of California has significantly reduced readmissions for its patients, including Medicare Advantage members, commercially insured individuals and dual eligibles
This resource also provides exclusive details from successful care transition management efforts at Geisinger Health Plan, McLeod Regional Medical Center, St. Peter's Hospital, Sutter Health, Durham Community Health Network and others.
These initiatives are particularly critical as utilization data is increasingly scrutinized and organizations are held increasingly accountable for both the quality and cost of the care they provide.
The program profiles in this 130-page resource cover everything from enhancements in the hospital discharge process to medication reconciliation ideas to better utilization of home visits during care transitions.
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P.S. – You may also be interested in these care transition resources: