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.

Care Transitions Toolkit 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.

This resource will also provide details on the following:

  • The contributions of embedded case managers to care transition management;
  • Best practices to improve medication adherence and compliance;
  • Health literacy tools to promote behavior change;
  • Strategies for matching high-risk patients with the appropriate clinical intervention;
  • and much, much more.

To learn more or to order your copy today, contact HIN at 888-446-3530 or visit online at:

Available in Single or Multi-User Licenses

A multi-user license will provide you with the right to install and use this information on your company's computer network for an unlimited number of additional workstations within your organization for a one-time fee. To have this valuable resource on your network, or to inquire about ordering bulk copies in print or Adobe PDF, please e-mail or call 888-446-3530.

P.S. – You may also be interested in these care transition resources: