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Improving Care Transitions

Improving care transitions between care settings is critical to improving individuals’ quality of care and quality of life and their outcomes. Effective care transitions:

  • Prevent medical errors
  • Identify issues for early intervention
  • Prevent unnecessary hospitalizations and readmissions
  • Support consumers preferences and choices
  • Avoid duplication of processes and efforts to more effectively utilize resources

Care transitions include the coordination of medical and long term services and supports (LTSS) when an individual is:

  • Admitted to a hospital, emergency room, or other for acute medical care
  • Discharged from a hospital to an institutional long-term care (LTC) setting, such as a skilled nursing facility/nursing facility (SNF/NF), inpatient rehabilitation facility (IRF), or intermediate care facility (ICF)
  • Discharged to community based LTC
  • Discharged from an institutional LTC care setting to community LTC or vice versa

Technical Assistance and Resources for States

The Centers for Medicare & Medicaid Services is committed to helping states and their providers undertake efforts to improve transitions and improve medical and LTSS coordination by providing technical assistance, resources, and facilitating the exchange of information about promising practices of high quality, high impact, and effective care transition models and processes. This includes outcomes to individuals with Medicaid.

Technical assistance and resources include:

  • Cross agency Partnership for Patients initiative is decreasing hospital readmissions by improving care transitions and community based care.
  • Find the contact information for Quality Improvement Programs (QIOs) in your state by accessing the QIO directory.
  • Hospital engagement networks (HENs) are working with community providers to improve transitions.
  • Aging and Disability Resource Center provides information for states and community organizations that want to identify and access a range of home and community based resources to make positive changes to their long-term services system including home based interventions.
  • Community-based Care Transitions Program (CCTP), created by Section 3026 of the Affordable Care Act, tests models for improving care transitions from the hospital to other settings and reducing readmissions for high-risk Medicare beneficiaries.
  • Money Follows the Person initiative assists states in their efforts to reduce reliance on institutional care while developing community-based long-term care opportunities.
  • Medicare resources help caregivers manage varying issues and lead balanced, rewarding lives.