The care transitions theme focuses on improving the coordination of care as patients move between care settings to reduce unnecessary or preventable re-hospitalizations. Nationally, within 30 days of discharge, more than 17% of Medicare patients are re-hospitalized. It is estimated up to 76% of those re-admissions may be preventable.
HQSI is one of only 14 organizations nationwide selected by the Centers for Medicare & Medicaid Services (CMS) to create pilot projects designed to respond to this critical need. An area encompassing 44 communities in Burlington and Camden counties was chosen to be the focus of this pioneering effort. Within this area, the 30 day re-hospitalization rate among Medicare patients is nearly 20%.
Over a three-year-period, the New Jersey Care Transitions Project will bring together healthcare providers and community partners in a campaign to improve patient care and reduce re-hospitalization rates. Special emphasis will be placed on those at highest risk. That includes: patients who experience myocardial infarction (heart attack), congestive heart failure, pneumonia, have chronic obstructive pulmonary disease (COPD) or diabetes
Key elements in the New Jersey Care Transitions Project include better communication among healthcare providers regarding individual patients, promotion of "best practices" at all levels of treatment, and recognition that fully informed patients can and should take an active role in healthcare decisions.
HQSI is partnering with Virtua, Southern New Jersey's largest multidisciplinary healthcare provider, with service sites in Burlington, Camden and Gloucester counties, as well as with non-Virtua providers. The pilot study will concentrate on communities served by Virtua's hospitals, nursing homes, home health agencies, and physician practices, as well as other nursing homes, home health agencies, private physician practices, inpatient rehabilitation facilities, dialysis centers, hospices, patients, families, community-based organizations and stakeholders in the targeted communities.
The project promises to have a profound impact on the lives of Medicare patients. At the same time, it is an innovative approach to reducing healthcare costs.
