title: A community-wide quality improvement project on patient care transitions reduces 30-day hospital readmissions from home health agencies.
abstract: Approximately 1 in 5 Medicare patients are rehospitalized within 30 days of discharge. The Harlingen Hospital Referral Region, an area defined by the Dartmouth Atlas as 35 ZIP codes in South Texas, reduced 30-day hospital readmission rates and associated costs through its participation in the Centers for Medicare & Medicaid Services Care Transitions project. The project emphasized a community-wide focus on 4 quality improvement areas: (a) the problem of rehospitalization, (b) improving cross-setting collaboration, (c) access to performance data, and (d) implementation of best practice interventions to reduce avoidable hospitalizations.
authors.affiliation: TMF® Health Quality Institute, Austin, Texas, USA. jmarkley@txqio.sdps.org
authors.forename: Jennifer
authors.initials: J
authors.lastname: Markley
authors.forename: Karen
authors.initials: K
authors.lastname: Sabharwal
authors.forename: Ziyin
authors.initials: Z
authors.lastname: Wang
authors.forename: Cindy
authors.initials: C
authors.lastname: Bigbee
authors.forename: Linda
authors.initials: L
authors.lastname: Whitmire
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003153:Community Health Services / Q000458:organization & administration; D003695:Delivery of Health Care / Q000458:organization & administration; D005260:Female; D019538:Health Care Surveys; D018574:Home Care Agencies / Q000191:economics*; D006760:Hospitalization / Q000191:economics / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D006278:Medicare / Q000191:economics* / Q000706:statistics & numerical data; D010347:Patient Care Planning / Q000458:organization & administration*; D058991:Patient Protection and Affordable Care Act; D010359:Patient Readmission / Q000191:economics* / Q000706:statistics & numerical data; D011050:Policy Making; D058996:Quality Improvement; D013781:Texas; D014187:Transportation of Patients; D014481:United States