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Care Transitions Toolkit
Care Transitions Toolkit
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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.

Consequently, 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 measurable savings to the Medicare program.

So critical are skills and expertise in patient handoffs between sites of care that the Case Management Society of America (CMSA) and the American Board of Quality Assurance and Utilization Review Physicians, Inc. (ABQAURP) are collaborating to create a sub-specialty certification for transitions of care.

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.

Download the executive summary of the Care Transitions Toolkit.

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 more 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. Q&A chapters answers more than 45 questions on various aspects of care transition management.

This guide also provides a complete set of 2010 benchmarks in improving care transitions from 87 healthcare organizations.

Table of Contents:

  • Chapter 1: 2010 Care Transitions Benchmarks
  • Chapter 2: SNF-Hospital Handoffs
  • Chapter 3: Multidisciplinary Post-Discharge Support
  • Chapter 4: Tactics to Reduce Medicare Rehospitalizations
  • Chapter 5: Q&A

Download the executive summary of the Care Transitions Toolkit.

The actionable information contained in the Care Transitions Toolkit is essential for healthcare organizations charged with reducing avoidable healthcare utilization costs resulting from poorly managed care transitions. It is also an excellent compendium of best practices against which organizations can evaluate their own efforts in the management of care transitions.

Publication Date: October 2011
Number of Pages: 130
ISBN 10: 1-937229-21-1(Print version); 1-937229-22-X (PDF version)
ISBN 13: 978-1-937229-21-4 (Print version); 978-1-937229-22-1 (PDF version)
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Care Transition Management: Strategies for Effective Patient Handoffs, an April 24, 2013 webinar, now available for replay
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