Care Transitions

Improving Community-Based Transitions of Care

Improving Care Transitions

The Centers for Medicare & Medicaid Services (CMS) recognized that cross-setting collaboration, partnership, and working across the care continuum with other health care and community-based providers are essential strategies to reducing 30-day readmissions.

From 2010-2016, the Medicare Payment Advisory Committee (MEDPAC) reported a decrease in the 30-day readmission rate from 16.7% to 15.6%. Of those patients who are re-admitted, the MEDPAC estimated that approximately 61% of the readmissions were preventable.

Community of Care Coalitions

As the IPRO QIN-QIO, we work across the care continuum to connect health care providers with community-based organizations to create community of care coalitions.

We assist coalitions in identifying community-specific needs and opportunities, sharing best practices, and supporting interventions that enhance the overall health of the community.

We help develop innovative solutions to improve care from hospital discharge, to rehabilitation, to home health care, and back into the community with additional supports.

We are committed to assisting communities in implementing evidence-based and data-driven methodologies to support sustainable, innovative improvements and enhanced resources for the communities and patients they serve.


The framework of the Care Transition Coalition, underpins its overall goals of:

  • Reducing hospital admissions and readmissions
  • Decreasing community-based adverse drug events (ADEs)
  • Understanding and addressing the unique needs of super utilizers
  • Monitoring access-to-care issues that may result in increased hospital utilization

Clinical and Quality Improvement Offerings

Technical Assistance

  • Facilitate and support interpretation of community-based root cause analyses
  • Support evidence-based and best practice intervention selection
  • Identify meaningful and feasible measurement strategies
  • Evaluate effectiveness of interventions and support innovative strategies that sustain goals

Tools and Education

  • On-demand, web-based education from recognized experts
  • Connection with peer providers for shared learning
  • Benchmarking and feedback data reports for comparative analysis
  • Educational resources for clinicians, staff, patients, and residents to support enhanced care coordination

Highlighted Tools and Resources

Addressing Drivers

  • Information Transfer
  • Patient and Family Activation
  • Standard and Known Care Processes
  • Trauma Informed Care
  • Social Determinants of Health
  • Medication Reconciliation
  • Substance Use
  • Access to Care

Best Practices

  • Connecting with Community Resources
  • Engaging Caregivers
  • Practicing Teachback
  • Screening for Social Determinants of Health

For Questions or Support