Integrating Care to Reduce Readmissions in New Jersey

In New Jersey and nationwide, too many older adults discharged from the hospital are readmitted within 30 days. Many of these readmissions can be prevented, but doing so takes a community-wide effort -- greater coordination on the part of healthcare providers across the healthcare continuum as well as increased patient and family involvement in their own care. This can be achieved through a community-based effort to integrate care. That’s where HQSI plays a role. Our services, which are underwritten by the Centers for Medicare & Medicaid Services, are free to New Jersey’s healthcare community. We offer the following:

• Community-based Care Transitions Program Funding Assistance 
• Community Coalition Development and Facilitation
• Care Integration Learning and Action Network

Why should you take advantage of these free services?

• Providing better patient care across the healthcare continuum is the right thing to do
• Under the Affordable Care Act, Medicare will reduce payments to hospitals with excessive readmission rates after 2012
• Emerging healthcare delivery and reimbursement models such as Accountable Care Organizations and Patient-Centered Medical Homes will reward physicians and providers who can demonstrate they can reduce avoidable readmissions. Your work on our projects can provide you with a competitive advantage

Key Resources

• Integrating Care for Populations and Communities Aim National Coordinating Center Toolkit
• National Transitions of Care Coalition (NTOCC) Compendium
• INTERACT II Resources (for Long Term Care)