Care Transitions
Quality Insights has been awarded a project to help hospitals, nursing homes, 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 will work to reduce unnecessary hospitalizations and readmissions that are not only harmful to the patient, but to Medicare’s spending as well.
Quality Insights will work 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, 10 home health agencies and 17 nursing homes have signed on to participate in the project.
Care Transitions activities will focus on the following areas:
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Community recruitment
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Interventions
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Monitoring
Issues of focus will be:
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Medication Management
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Post-discharge follow-up
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Plans of care for those patients moving across health care settings