Hospital Interventions to Improve Transitions of Care and Reduce Hospital Readmissions

HSCRC’s ARR initiative has put in place incentives to support participating hospitals’ focus on improving the transition out of the hospital for all patients. Although the work to improve care transitions starts with a hospital-based team, Maryland participating ARR hospitals have submitted intervention plans to support engagement of representatives from skilled nursing facilities, home health agencies, ambulatory practices, other community based services, as well as patients and family caregivers as part of the “transitions” teams. Hospitals have designed there interventions to:

• Enhance risk of readmission assessment;
• Enhance assessment of post-discharge needs;
• Enhance teaching and learning;
• Enhance communication with patients, care team members and an array of community-based providers at discharge;
• Support timely post-acute follow up.

Each of the ARR hospitals listed below has submitted their care transition Intervention Plans individually or as part of a hospital system. HSCRC applauds hospital efforts to improve care transitions and reduce readmissions. In addition to the Intervention Plans, HSCRC will soon post the quality indicators hospitals have identified that they will measure to ensure they are implementing their interventions and the interventions are effective.

Click Interventions Tracking 2012-06-12 to view the hospital intervention plans in an excel file with hospitals/systems listed in worksheets alphabetically.