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The Evidence That the Readmissions Rate (Readmissions/Hospital Discharges) Is...
By Joanne Lynn M.D. [Also see companion post by Stephen F. Jencks, M.D., M.P.H.] Care transitions improvement programs have been effective in helping the health care system both become more effective...
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Protecting Hospitals That Improve Population Health
by Stephen F. Jencks, M.D., M.P.H. [Also see companion post by Joanne Lynn, M.D.] Issue. The Medicare Readmission Reduction Program (MRRP) encourages hospitals to reduce readmissions within 30 days of...
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From Hospital to Home: The Missing Element in Discharge Planning
By Anne Montgomery and Leslie Fried of the National Council on Aging One of the hallmarks of the 21st century—increased longevity of the population—will increasingly drive federal, state, and local...
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Readmissions Count: Should CMS Revise Its Calculations?
by Dr. Joanne Lynn When community coalitions apply for funding from the Community-Based Care Transitions program of the Centers for Medicare and Medicaid (CMS), they have to show that they will reduce...
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JAMA Report Finds Community Collaboration Key to Reducing Hospitalizations...
By Dr. Joanne Lynn The latest issue of JAMA features our paper describing an exciting and successful initiative from the Centers for Medicare and Medicaid Services (CMS) and fourteen of its quality...
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Learning from Reviewing Readmissions: Tools You Can Use
A colleague asked an important question: Which tools are best for reviewing causes of readmissions? Two examples, from Georgia and New Jersey, are attached to this posting. Georgia’s form requires...
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Room to Grow: Palliative Care’s Place in Care Transitions
by Larry Beresford The Hospital Association of Southern California, which convened a Palliative Care Committee to provide mutual support among its members working on palliative care initiatives,...
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CMS Announced First Awards for CCTP Funding
CMS announced the first sites selected for the Community Based Care Transition Program. Please see the links below for the list of sites and an updated fact sheet. As noted above, we continue to accept...
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SAGE: Bridging the Divide between Acute Medical Care and Social Services in...
By Dr. Kyle Allen and Susan Hazelett The Summa Health System/Area Agency on Aging, 10B/Geriatric Evaluation Project(SAGE) is a collaboration between an integrated health system and the local Area...
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Reaching Rural Residents: Improving Care Transitions in Western New York State
The P2 Collaborative of Western New York [name was changed to Population Health Collaborative in 2017] represents a different spin on the Community-based Care Transitions Program (CCTP) model. It is...
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