Care Transitions

Since its inception, the Alliance has examined the ways in which home health care providers can improve the transition of a patient from acute care to post-acute home health care or from home health care to other settings. The movement of patients across settings, referred to as "care transitions," is a process that requires strong partnerships between long-term post-acute care settings like home health care and other providers such as hospitals, primary care physicians, and outpatient clinics.

From identifying key models of care transitions to working towards interoperable Electronic Health Records (EHRs), the Alliance has continually brought together thought leaders and clinical experts to identify methods of improving a patient's care transitions.

2012 Care Transition Recommendations

• The Alliance submitted comments on proposed regulatory rules, urging the Department of Health and Human Services (HHS) to continue to include home health care when building a technological infrastructure that will allow providers to share patient information across settings. To read the May 2012 comments, please click here.
• On May 22, 2012, the Alliance hosted a roundtable discussion of a readmissions quality reporting standard and the development of a home health model for care transitions — two standards for the home health community to help to demonstrate the value of home health and improve the credibility of the industry. The roundtable brought together clinical and quality officers from the Alliance's Quality and Innovation Work Group as well as guests including: Ms. Christine Lang, from OCS HomeCare, Dr. Margaret Terry, from the Visiting Nurse Associations of America (VNAA), and Dr. Robert Rosati, from the Visiting Nurse Service of New York (VNSNY). As a result of the roundtable, the Alliance identified pertinent research questions for further study with plans to reconvene in late Fall of 2012.

2011 Care Transition Recommendations

• A growing body of independent clinical and health services research documents that the transitions from hospital discharge to post-acute care settings or the community can be a time of particular vulnerability for patients who rely on Medicare. Poorly coordinated care transitions have also been shown to be costly, especially for patients who are readmitted to the hospital because of discontinuities in their care or exacerbations of their health conditions. Managing a patient's care transitions are critical at a time when the nation is seeking new ways to control costs. To examine this issue in further depth, the Alliance published a White Paper on Care Transition Coaching, titled "Care Transition Coaching: A New, Community-Based Home Health Program." To read the paper, click here.

2010 Care Transition Recommendations

• Alliance joined the University of Pennsylvania and the Joint Commission in sponsoring the inaugural Optimizing Home Health in Care Transitions Summit. Held at the University of Pennsylvania's School of Nursing, the Summit brought together thought leaders and experts from across the health continuum in an effort to build consensus on defining best practices for optimizing patient outcomes as they transition through care settings and to identify cost-saving opportunities related to unnecessary institutionalization.
  
  

2009 Care Transition Recommendations

• Click here to read recommendations to the Centers for Medicare & Medicaid Services (CMS), on critical information that needs to be communicated between home health and other providers to ensure an optimal transition between settings.