The Centers for Medicare & Medicaid Services (CMS) has announced the 14 communities around the nation that have been chosen for the Agency's Care Transitions Project, seeking to eliminate unnecessary hospital readmissions.

"Our data show that nearly one in five patients who leave the hospital today will be re-admitted within the next month, and that more than three-quarters of these re-admissions are potentially preventable," said CMS Acting Administrator Charlene Frizzera. "This situation can be changed by approaching health care quality from a community-wide perspective, and focusing on how all of the members of an area's health care team can better work together in the best interests of their shared patient population."

The goal of the Care Transitions Project is to improve health care processes so that patients, their caregivers, and their entire team of providers have what they need to keep patients from returning to the hospital for ongoing care needs. By promoting seamless transitions from the hospital to home, skilled nursing care, or home health care, this community-wide approach seeks, not only to reduce hospital readmissions but to yield sustainable and replicable strategies that achieve high-value health care for Medicare beneficiaries



"The Care Transitions Project is a new approach for CMS," said Barry M. Straube, M.D., chief medical officer for CMS and its Office of Clinical Standards & Quality director. "Rather than focusing on one global problem and trying to apply a one-size-fits-all solution across the country, Care Transitions experts will look in their own backyards to learn why hospital re-admissions occur locally and how patients transition between health care settings. Based on this community-level knowledge, Care Transitions teams will design customized solutions that address the underlying local drivers of re-admissions."

Communities in the following regions have been selected to participate in the Project: Providence, R.I.; Upper Capitol Region, N.Y.; Western Pennsylvania; Southwestern New Jersey; Metro Atlanta East, Ga.; Miami.; Tuscaloosa, Ala.; Evansville, Ind.; Greater Lansing Area, Mich.; Omaha, Neb.; Baton Rouge, La.; North West Denver, Colo.; Harlingen, Texas; and Whatcom County, Wash. The work of the Care Transitions Project will respond to the unique needs of each of the 14 communities.



Each of the Care Transitions communities is led by a state Quality Improvement Organization (QIO). QIOs work throughout the country as part of CMS's quality program to help health care providers, consumers and stakeholder groups to refine care delivery systems to make sure all Medicare beneficiaries get the high-quality, high-value health care they deserve. Each QIO in the project is required to work with partners to implement the following:

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