Let's work together.
Twenty-five partner organizations are working with RWJF to inform and spread the work being done by providers, patients and communities to improve care transitions and reduce avoidable readmissions.
Twenty-five partner organizations are working with RWJF to inform and spread the work being done by providers, patients and communities to improve care transitions and reduce avoidable readmissions.
AARP is a nonprofit, nonpartisan social welfare organization with a membership and offices in all 50 states, the District of Columbia, Puerto Rico, and the U.S. Virgin Islands. Our mission is to help people 50+ have independence, choice and control in ways that are beneficial and affordable to them and society. We strive to help our members live long and healthy lives, in part, through the provision of materials that help them become actively engaged in their health care. AARP produces AARP The Magazine, AARP Bulletin; AARP VIVA, (the only bilingual U.S. publication dedicated exclusively to the 50+ Hispanic community); and our website, www.aarp.org. As a trusted source of information, these communication channels offer a wide range of information about health and health care that is especially suited to people 50+.
AARP collaborates with government and private sector partners with whom we co-brand materials designed to help older adults stay healthy, such as the “Stay Healthy at 50+” brochures and consumer guides that compare medical treatments. We offer information on a wide array of topics, such as flu and other vaccines for older adults; guides to make the best use of health coverage, including Medicare; tools to calculate BMI; and resources to support medication management education and outreach, such as the AARP Doughnut Hole Calculator and the Drug Savings Tool (with content provided by Consumer Report’s Best Buy Drugs). We also maintain a Caregiver Resource Center to provide information and support for family caregivers.
The focus of the 2013 Care About Your Care initiative is of great importance to AARP’s members, many of whom either have chronic illnesses and are likely to experience hospitalization during the course of the year or are family caregivers of those who do. The barriers to high quality health care for this group include fragmented care, poor transitions between and among settings, and misaligned payment incentives. AARP addresses these challenges not only through our publications but also through our advocacy efforts that support quality improvement, incentives to ensure smooth transitions, performance assessment, public reporting, and consumer engagement.
The American College of Physicians (ACP) is committed to raising awareness among its 133,000 internal medicine physician members about the need to improve transitions of care and reduce avoidable hospital readmissions.
Internal medicine physicians, who specialize in the prevention, detection, and treatment of illness in adults, are a key segment of the medical community for helping to advance the process of coordinating care. Through its web-based Medical Home Builder, ACP provides resources and guidance to strengthen the comprehensive ambulatory care of patients in ways that will enhance care coordination and transitions of care across ambulatory and inpatient environments, ultimately helping to reduce avoidable hospitalization and hospital readmissions. Through its High Value Care initiative, ACP is working to reduce unnecessary care and the costs associated with that care. This effort aligns with the goals of the Care About Your Care initiative, since reduction of unnecessary admissions and making sure care is effectively and efficiently coordinated are keys to reducing waste and unnecessary spending. ACP has also partnered with The Joint Commission in its Preventing Avoidable Heart Failure Hospitalizations Project, which is focused on identifying how hospitals and community-based physician practices can work together more effectively to prevent avoidable hospitalizations for people with heart failure.
The American Health Care Association and National Center for Assisted Living launched a Quality Initiative in February 2012. The Initiative builds upon existing work of the long term and post-acute care profession in advancing quality care by setting specific, measurable targets to further improve quality in America’s skilled nursing centers and assisted living communities. The Initiative includes a goal to safely reduce the number of hospital readmissions within 30 days during a skilled nursing care center stay by 15 percent by March 2015. Currently, one in four persons admitted to a skilled nursing care center from a hospital is readmitted to the hospital within 30 days during their skilled nursing stay. This not only has negative physical, emotional and psychological impacts on these individuals, but also costs government programs like Medicare billions of dollars.
To achieve our goal, we have provided our members with their rehospitalization rates benchmarked to others and promoted the INTERACT II program, an evidence-based program that has been shown to safely reduce rehospitalizations from skilled nursing centers.
We know that more can be done to prevent sending seniors back to the hospital while they receive care in long term and post-acute care settings. We have provided several resources to help our members reach this goal.
The American Health Quality Association (AHQA) is proud to be a partner in Care About Your Care. Across the country, as many as one in five older adults return to the hospital within 30 days of being discharged—costing the Medicare program billions of dollars each year. These readmissions are not just a hospital problem or a patient problem—they are a community problem, requiring all sectors of the community to work together to ensure that these transitions from the hospital to home or other facility are more effective.
As the organization that represents Quality Improvement Organizations (QIOs)—organizations funded by the Centers for Medicare & Medicaid Services (CMS) to help improve health care delivery, safety and efficiency in every state—we work to improve the quality of care across America. QIOs share information about best practices with physicians, hospitals, nursing homes, home health agencies and others, and work with health care providers to identify opportunities and provide assistance for improvement.
A January 2013 study in the Journal of the American Medical Association shows how state-based QIOs systemically coordinated community-based efforts with hospitals and other providers to improve the quality of care transitions and reduce rehospitalization rates among Medicare patients by nearly six percent in 14 select communities. QIOs in every state are now working to transfer the lessons of these pilot communities to others nationwide to help improve patient care for millions of seniors, while also reducing Medicare costs. We look forward to collaborating with the Robert Wood Johnson Foundation and others to improve the quality of care for all Americans.
Delivering the right care, at the right time, in the right setting is the core mission of hospitals across the country. America’s hospitals are committed to continuously working to improve the safety and quality of care they deliver for the patients and communities they serve. To that end, hospitals are working diligently to improve care transitions and reduce avoidable readmissions.
Preventing avoidable readmissions is a system-wide issue that involves hospitals, physicians and other providers, as well as patients and families themselves.
It is important to remember that not all readmissions can or should be avoided. There are a number of appropriate readmissions that are part of a patient care plan; re-admitting a patient to a hospital is a decision made by dedicated physicians and is only done with the best interests of the patient in mind. Other readmissions may occur due to an unforeseen event, such as an accident or other trauma that is unrelated to the original cause for hospitalization. These readmissions are appropriate and should not be a cause for provider penalties.
Hospitals are moving forward with efforts to reduce avoidable readmissions as part of their continuous improvement in quality and patient safety. They are testing various approaches, looking at innovative programs focused on improving care transitions, bolstering discharge planning and follow-up care and strengthening linkages with other community providers.
The American Hospital Association is committed to helping hospitals improve the quality of care they deliver every day and AHA does so by sharing tools, resources and best practices with its members and by working with federal lawmakers, regulators and research agencies to create a policy environment in which quality and safety can thrive.
The American Nurses Association (ANA) has worked consistently to improve care transitions and care coordination, including raising awareness about how these approaches improve patient health and satisfaction and control health care costs. As the largest of the health care professions, more than 3.1 million registered nurses (RNs) provide care coordination services in many settings, including hospitals, outpatient surgery centers, long-term-care facilities and community-based locations such as schools, clinics and private practices.
Effectively managing patients’ transitions from health care facilities and coordinating care in the community helps prevent hospitalizations and avoidable hospital readmissions. To heighten awareness, ANA issued the position statement, Care Coordination and Registered Nurses’ Essential Role, and the report, The Value of Nursing Care Coordination, which highlights studies that show care coordination’s positive impact on patient outcomes, health system efficiency and health care costs.
For RNs, care coordination is a long-held core professional standard and competency. Care coordination involves developing care plans guided by patients' needs and preferences, educating patients and their families at discharge, and facilitating continuity of care for patients across settings and among providers. RNs are integral to this process.
Given that care coordination is one of the strategies fueling health care reform today, ANA is working to develop robust definitions of care coordination and quality outcomes that will help nurses and other health care professionals improve the delivery and quality of patient care.
ANA is pleased to support the Care About Your Care campaign to help empower consumers to be active participants in their health care and make informed choices.
Karen A. Daley, PhD, RN, FAAN
American Nurses Association
This year, Care About Your Care has asked stakeholders to share best practices in improving care transitions and eliminating preventable hospital readmissions, taking on what our community believes are two of the most critical challenges faced by the system. Innovative programs developed by health plans, and new models of care promoted by health plans have demonstrated terrific results in these areas, and we are pleased to share information with our colleagues across the stakeholder community.
As we increasingly focus on the role of patients themselves, Care About Your Care is helping to advance patient-centered care by addressing the fundamental question ‘what can we do as consumers?’ This year, the initiative has taken another important step by developing tools that include tips for patients to avoid readmissions and transition from the hospital successfully.”
President and CEO
America’s Health Insurance Plans
Nearly one in five Medicare patients discharged from a hospital—approximately 2.6 million seniors—is readmitted within 30 days, at an annual cost of over $26 billion. Our top priority is ensuring people with Medicare get the high-quality health care they need, expect and deserve. As part of that effort, the Centers for Medicare & Medicaid Services (CMS) is pursuing a variety of efforts to reduce avoidable hospital readmissions and improve care transitions. These efforts help prevent medical complications after a person leaves the hospital.
The Affordable Care Act provides CMS with many opportunities to improve care transitions and reduce avoidable readmissions.
For high-risk Medicare beneficiaries, the Community-based Care Transitions Program provides funding to over 75 community-based organizations partnering with hospitals across the country to help manage care transition services. The Partnership for Patients works with over 3,700 hospitals nationwide to improve hospital safety and implement strategies with the goal to reduce hospital-acquired conditions by 40 percent and readmissions for all patients by 20 percent. Medicare payment reforms are working to reduce preventable readmissions. Utilizing existing Quality Improvement Organizations that work to improve quality in each state, CMS is helping these organizations focus on care transition interventions. Many other CMS programs have focused on improving care and reducing avoidable hospitalizations among the people whom CMS serves.
We are proud to support Care About Your Care in the effort to reduce preventable hospital readmissions, which will improve the quality of care for Medicare, Medicaid, the Children’s Health Insurance Program (CHIP) beneficiaries and all Americans.
Deputy Administrator and Director for the Center of Medicare
Centers for Medicare and Medicaid Services
The Children’s Hospital Association welcomes the opportunity to partner with the Robert Wood Johnson Foundation and other leading health care quality improvement organizations on the Care About Your Care initiative. We applaud the initiative’s purpose to celebrate, inform and spread the steady work being done to ensure patients and providers share responsibility for quality health care.
Representing more than 200 children’s hospitals nationwide, the Association is committed to improving the health and health care of our country’s 76 million children. From the neonatal intensive care unit where pediatric nurses and physicians deliver cutting edge medical care to fragile newborns to home health care settings where patient care is delivered and managed effectively outside of hospital walls, children’s hospitals innovate solutions that improve pediatric care while lowering costs.
The 2013 Care About Your Care initiative’s focus on improving care transitions in order to reduce avoidable hospital readmissions aligns with objectives of the Association’s Quality Transformation Network (QTN), a group of 172 medical units in 93 hospitals collaborating to improve care and outcomes for high-impact clinical issues. Children’s hospitals in the QTN collaborate and learn from each other in how best to prepare families to provide continuing care for children post-discharge, in their own homes.
For example, children who receive peritoneal dialysis or chemotherapy at home require careful management of catheters and central lines to avoid infection and potential readmission. Children’s hospitals in this network strategize and continually improve how to train parents and caregivers to maintain aseptic technique, conduct proper hand hygiene and perform best practice for maintenance of lines. By preventing these infections in the home setting, these projects prevent hospitalizations, reduce costs, allow patients to continue home-based care and importantly maintain normal school and family activities.
Despite the challenging fiscal environment at the federal level, the Association is committed to working with children’s hospitals to advocate increased funding for innovative, accountable models that improve pediatric health care while lowering costs. As a nation, our future depends on the health of children today.
Marlene Miller, M.D., MSc.
Vice President, Quality Transformation
Children’s Hospital Association
Consumer Reports Health is pleased to support the Care About Your Care effort to improve care transitions and reduce avoidable readmissions. The goals of the effort are well aligned with our goals at Consumer Reports to improve patient safety and the quality of consumers’ experiences in health care.
Our organization has been working on this issue in various ways:
We look forward to supporting Care About Your Care in 2013. Visit http://consumerhealthchoices.org/campaigns/care-about-your-care/ for Consumer Reports hospital survival guide resources.
Improving the quality of health care in our country is no small task, which is why HealthPartners is proud to support the Robert Wood Johnson Foundation’s Care About Your Care effort. At HealthPartners, our care system has reduced readmissions from 11.5 percent to 9.7 percent since 2009. This has reduced medical costs by more than $3 million. Specific examples of our strategies include:
As an integrated health care delivery and financing organization, HealthPartners has a unique opportunity to improve care transitions and reduce avoidable readmissions among our 500,000 patients and 1.4 million members. The work we do at our four hospitals, 50 primary and specialty care clinics and through our health plan is designed to achieve the Triple Aim of health care: better health, an exceptional experience and more affordable care.
The Care About Your Care effort highlights the work being done in this area at HealthPartners and around the country, and we are honored to be included.
Executive Vice President
Using health IT, consumers, patients, and clinicians can improve the quality, cost-effectiveness, safety and access to healthcare. HIMSS and its members equip frontline clinicians and healthcare workers with IT knowledge to engage and empower consumers.
The Leapfrog Group is pleased to again join with leading healthcare organizations to support Care About Your Care.
Aiming to quickly catalyze a movement to improve patient safety in hospitals, thereby reducing complications and readmissions, in 2012 The Leapfrog Group launched the Hospital Safety Score, an A, B, C, D, or F rating on how safe hospitals are for patients. The Hospital Safety Score enables patients to quickly assess a hospital’s safety and make an educated decision on which hospital is best for their family’s care.
To date, millions of patients have accessed our hospital ratings on www.HospitalSafetyScore.org and www.LeapfrogGroup.org/CP. It is clear that patients value quality and safety information available on hospitals and are beginning to use this information to select hospitals for care.
We encourage consumers to continue using information available from The Leapfrog Group and other ratings organizations to research hospitals in advance and be prepared for an emergency or a planned procedure. Selecting a hospital that has a better record of safety and quality performance is most likely to result in a safer hospital stay with fewer complications and readmissions. We also encourage employers and purchasers of healthcare to use these ratings to guide their employees to safer care. We thank the Robert Wood Johnson Foundation for their leadership in promoting consumer awareness around these issues.”
President & CEO
The Leapfrog Group
The National Alliance for Caregiving is glad to be able to partner with the Care About Your Care 2013 initiative. Caregiving touches almost every family and in very different ways – different health conditions; different situations; even different cultures. Understanding the family caregiver and what they need to take care of themselves as well as their loved one is why the Alliance has been serving America’s nearly 66 million family caregivers.
Established in 1996, The National Alliance for Caregiving is a non-profit coalition of over 50 national organizations focusing on advancing family caregiving through research, innovation and advocacy. Alliance members include grassroots organizations, professional associations, service organizations, disease-specific groups, government agencies, and corporations. The Alliance conducts research, does policy analysis, develops national best-practice programs, and works to increase public awareness of family caregiving issues. NAC also works with close to 100 national coalitions to help strengthen them, through research; advocacy training; education and outreach so they can better address the needs of family caregivers.
Recognizing that family caregivers make essential social and financial contributions toward maintaining the well-being of those they care for, the Alliance is dedicated to being the foremost national resource on family caregiving to improve the quality of life for families and care recipients. NAC understands the importance of care transitions for patients as well as the family caregiver(s), often sharing resources on care transitions through our list serves and social media. The Alliance published with the United Hospital Fund of New York, A Family Caregiver’s Guide to Hospital Discharge Planning funded by Metlife Foundation. This guide, also published in Spanish, provides valuable information for the family caregiver on the process of leaving the hospital.
Gail Gibson Hunt
National Alliance for Caregiving
National Association of Public Hospitals and Health Systems (NAPH) members know care transitions offer valuable opportunities to meaningfully improve patient outcomes and reduce readmissions. Improving care transitions, a goal NAPH shares with the Care About Your Care initiative, takes an important step toward better care coordination, quality, and value. NAPH members view reducing readmissions as central to their mission of caring for vulnerable people – nearly 90 percent report making it an institutional priority – and many have innovative programs in place toward this end.
NAPH, through its NAPH Safety Network (NSN), has been particularly active in national efforts to reduce avoidable hospital readmissions. The NSN, one of 26 hospital engagement networks under the federal Partnership for Patients, aims to reduce nine hospital-acquired conditions by 40 percent and readmissions by 20 percent by the end of 2013. These are critical goals, especially for safety net patients, who face cultural and socioeconomic challenges that can contribute to poorer outcomes and re-hospitalizations. Barely more than a year old, the NSN has made notable progress, including dramatically lower rates of 30-day diabetes and heart failure readmissions and significant drops in hospital-acquired conditions. Lessons learned through the work of the 29 NSN participants, all NAPH members, will drive best practices at all hospitals and health systems and better care for all patients.
NAPH offers resources to support sharing of successful strategies to reduce readmissions, including webinars, presentations, and publications. Visit the NAPH website for these and other member-developed innovations, evidence-based tools and programs.
NCQA is a non-for-profit organization dedicated to improving the quality of health care. Since our founding in 1990, we have been driving improvement through the health care system and helping to elevate the issue of health care quality to the top of the national agenda. Transforming our health care system requires the collected will and resources of many – from large employers and policymakers to doctors and patients to health plans and more. This is why NCQA is proud to be a partner in the Care About Your Care coalition.
Among the NCQA initiatives directly supporting improving care transitions and reducing avoidable hospital readmissions are:
The National Partnership for Women & Families is proud to be a part of Care About Your Care because we believe all Americans deserve access to comprehensive, coordinated, quality health care. The hard work of reforming the health care system is well underway and, now more than ever, consumers must work side-by-side, as equal partners with providers and payers in the design, implementation, and evaluation of new initiatives aimed at improving quality and lowering costs. To that end, the National Partnership is fostering consumer-provider partnerships aimed at redesigning health care delivery by improving transitions, reducing avoidable hospital readmissions, and more.”
Debra Ness, President of the National Partnership
The National Partnership for Women & Families is a nonprofit, non-partisan organization that has been working for 40 years to advance issues essential to women and families, with a focus on quality, affordable health care, fairness and equal opportunity in the workplace, and policies that help women and men meet the dual demands of work and family.
The National Partnership leads the Campaign for Better Care, which aims to ensure that the reformed health care system provides the comprehensive, coordinated, patient- and family-centered care that older adults and individuals with multiple health problems need. The National Partnership also provides technical assistance and support to 16 Aligning Forces for Quality Alliances as they engage consumers and advocates in improving the quality of health care and the overall health of their communities.
Learn how to improve care transitions and prevent avoidable hospital readmissions, and pick up nursing and medical education con-ed credits.
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