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Care Transitions

The Care Transitions project goal is to improve the quality of care of Medicare beneficiaries by reducing unnecessary readmissions to hospitals that may increase risk or harm to patients and cost to Medicare. FMQAI is one of 14 Quality Improvement Organizations (QIOs) selected by the Centers for Medicare & Medicaid Services (CMS) to participate in the Care Transitions project designed to serve target populations unique to each selected state.

FMQAI will partner with consumers, physicians, hospitals, nursing homes, home health agencies and community organizations to implement system-wide quality improvement interventions in targeted areas of Miami-Dade County, Florida. These improvement interventions will address issues in medication management, post discharge follow-up and plans of care for patients who move across health care settings. Further, these partnerships will strive to promote patient safety through improved care coordination between healthcare providers.

Opportunities for Improvement

The process by which patients move from hospitals to other care settings is increasingly problematic as hospitals lengths of stay shorten and care becomes more fragmented. Medicare patients report greater dissatisfaction related to discharges than to any other aspect of care that CMS measures. This situation can be changed. FMQAI will work with healthcare partners to identify and implement provider and community system-wide quality improvement interventions that address:

Reasons for rehospitalization with particular focus on high risk diseases of Heart Failure, Myocardial Infarction and Pneumonia
Medication Reconciliation as patients transition between settings
Communication and coordination of patient services between a variety of practitioners in multiple settings
Patient empowerment to foster increased patient responsibility for the self management of their disease conditions.