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Current initiatives focusing on coordination and continuity of care throughout episodes of illness.
The Hospital Engagement Networks

Through the Partnership for Patients, 26 state, regional, national and hospital system organizations serve as Hospital Engagement Networks. The Partnership for Patients and 3,700 of its participating hospitals are focused on making hospital care safer, more reliable, and less costly through the achievement of two goals:

1. Making Care Safer. By the end of 2013, preventable hospital-acquired conditions would decrease by 40% compared to 2010.

2. Improving Care Transitions. By the end of 2013, preventable complications during transition from one care setting to another would be decreased so that all hospital readmissions would be reduced by 20% compared to 2010. Learn more about the 26 Hospital Engagement Networks.

Quality Improvement Organizations

Quality Improvement Organizations Health Services Advisory Group of California (HSAG of California) is the state's contracted Medicare Quality Improvement Organization (QIO). QIOs in every state and territory, united in a network administered by the Centers for Medicare & Medicaid Services (CMS), are collaborating with partners to assist communities and providers with reducing avoidable hospital readmissions. HSAG of California launched the No Place Like Home Campaign website which offers regional and statewide Medicare Fee-for-Service readmissions data, a calendar for all statewide readmission events, as well as various tools and resources.

Visit HSAG of California's readmissions website
Learn more about QIOs
Download the CMS Care Transitions Fact Sheet

Another major Partnership for Patients network includes the 47 sites awarded to participate in the Community-Based Care Transitions Program. These sites each constitute a collaborative community effort including community-based organizations. Through the program, these sites are testing models for improving care transitions from the hospital to other settings and for reducing readmissions for high-risk Medicare beneficiaries.

State Action on Avoidable Rehospitalizations (STAAR)

The STAAR initiative is a multi-state, multi-stakeholder approach to dramatically improve the delivery of effective care at a regional scale. The STAAR initiative aims to reduce rehospitalizations by working across organizational boundaries and by engaging payers, stakeholders at the state, regional and national level, patients and families, and caregivers at multiple care sites and clinical interfaces.

Learn more about STARR
The Institute for Healthcare Improvement (IHI)

IHI is an independent not-for-profit organization and is a leading innovator in health and healthcare improvement worldwide.

The Health Research & Educational Trust (HRET)

HRET is an affiliate of the American Hospital Association, and is leading a Hospital Engagement Network to improve patient safety, reduce complications and preventable hospital readmissions and save lives.

The following are materials provided by HRET on Reducing Avoidable Readmissions: 

Agency for Healthcare Research & Quality (AHRQ) Reducing Avoidable Hospital Readmissions

Health Care Leader Action Guide to Reduce Avoidable Readmissions (PDF)
The National Transitions of Care Coalition

NTOCC is a group of concerned organizations and individuals who have joined together to address problems associated with transitions of care: the movement of patients from one practice setting to another. Click here to learn more about how improved communication and coordination between professionals, patients, and caregivers can improve lives and prevent unnecessary hospital readmissions.

Aligning Forces for Quality (AF4Q)

The Robert Wood Johnson Foundation‘s (RWJF) signature effort to lift the overall quality of health care in targeted communities, has turned its attention to improving the quality of care across settings. Among its many activities, AF4Q is working with its 16 community alliances across the nations to define problems related to care transitions and care across settings, design interventions, and measure and improve the quality of care.

Learn more about the AF4Q
The Center for Healthcare Research & Transformation (CHRT)

The CHRT illuminates best practices and opportunities for improving health policy and practice. Here you will find a list of effective readmissions reduction interventions.

Acute Care Readmission Reduction Initiatives: Major Program Highlights (PDF)
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