Quality Insights of Pennsylvania

Care Transitions

Quality Insights is currently working on a community-based, cross-setting project to help hospitals, skilled nursing facilities, home health agencies and physician offices improve coordination across the continuum of care. By promoting efficient transitions from hospital to home, skilled nursing care or home health care, our collaborators work to reduce unnecessary hospitalizations and readmissions that are not only harmful to the patient, but to Medicare’s spending as well. The inclusion of community resources, such as Area Agencies on Aging, is vital to the project's success.

Quality Insights works with Pennsylvania providers in Allegheny, Fayette, Washington and Westmoreland Counties. The community is part of the Pittsburgh Metro Area approximately 30 miles southeast of the city. Five hospitals, two in-patient rehabilitation facilities, one in-patient psychiatric unit,  six home health agencies, 12 skilled nursing facilities have signed on to participate in the project.

Care Transitions Cross-Setting Interventions are focusing on:

• Care Transitions Intervention ^SM
• Care Transitions Coaching Activities - Transition Coaches^TM
• Implementation of the CARE (Continuity Assessment Record & Evaluation) Tool
• The Four Pillars^SM
  •     Medication Self-Management
  •     Red Flags
  •     Follow-up
  •     Personal Health Record
• Discharge process improvement
• Post-discharge follow-up
• Handover management communication
• Plans of care for those patients moving across health care settings

Visit our Care Transitions Resources Page to download tools and access important information.


Provider Settings
Below is a description of each of the provider settings involved in the Care Transitions cross-setting project. 
  

Home Health

Home heath providers are a vital part of the care transitions coordination of care. By providing care for those unable to leave their homes, home health agencies work to help individuals remain as self-sufficient as possible in their own homes, thus avoiding institutional long-term care. Diverse in its makeup, home health care includes nursing care as well as other services, like physical and occupational therapy, speech-language therapy, and medical social services and personal care services. The diverse nature of home health services presents various challenges to quality measurement that differ from those found in a more traditional hospital-like setting.
 

Hospital

Hospitals serve as a vital piece of the care transitions coordination of care by providing inpatient diagnostic and therapeutic services for a variety of medical conditions, both surgical and nonsurgical. In addition, most hospitals provide some outpatient services, particularly emergency care. Health care provided in hospitals is complex and continuously evolving, showing great variation over time, across regions, and among populations. It is subject to the latest developments in scientific discovery, newly emerging environmental circumstances, and ever changing national priorities. Involving as it does the medical care of human beings; many issues of broad public policy including access to care, patient's rights, health information security, workforce development and financing are often defined and put into action within the hospital.
 
 

Skilled Nursing Facilities

Skilled nursing facilities serve a vital piece of the care transitions coordination of care by providing a wide range of personal care and health services. Skilled nursing facilities provide residents with 24-hour individualized support services. The differences in needs, characteristics, circumstances, expected outcomes, and long-term status of elders residing in nursing homes requires that staff employ a variety of techniques and strategies to provide quality care and ensure the quality of life for each resident.
 

Physician Office

Physicians in the outpatient setting provide chronic disease management and preventive services to millions of Medicare beneficiaries in the United States. To successfully achieve sustained improvement in health care, physicians need to redesign processes to meet the needs of patients to improve cross-setting processes and communication.