Improving Care Transitions/Reducing Readmissions

eQHealth is bringing together hospitals, nursing homes, patient advocacy organizations and other stakeholders in community coalitions.

These coalitions will be working toward seamless transitions from the hospital to home, skilled nursing care, home health care or hospice.  Process improvements address medication management, post-discharge follow-up, and plans of care for patients who move across health care settings.

The goals are to reduce readmissions statewide through coalition efforts and best practice sharing through a statewide learning and action network.

CMS Hospital Readmissions Reduction Program (HRRP) - An Overview (PDF of October 2011 PPT presentation)

Opportunity for Quality Improvement

The process by which patients move from hospitals to other care settings is increasingly problematic as hospitals shorten lengths of stay and as care becomes more fragmented. Improved health care processes at and after discharge correlate with substantial reductions in early rehospitalization for particular conditions, such as heart failure. In addition, prior and ongoing eQHealth work has assisted providers in analyzing data and in identifying and addressing gaps in care in areas such as transitions and end-of-life planning and care.

Community Coalitions

Care Transitions
Learning & Action Network

LHA/eQHealth
Reducing Readmissions Training Sessions - Monthly Call Calendar

Community-Based Care Transitions Program (CCTP)

End of Life Care (LaPOST)

Tools & Resources

2011 Louisiana Quality Summit & Awards Wrap-up
PLUS Award Winners