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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.

A Home health model for care transitions

In January 2014, the Alliance released a new resource outlining a model and tools for effective care transitions, which outlines an evidenced based approach to successfully complete the transition from hospital to home health care while greatly reducing the risk of rehospitalization.

Improving Care Transitions Between Hospital and Home Health: A Home Health Model for Care Transitions
Press Release

Additional Resources: 
VNAA Blueprint for Excellence
Sutter Center for Integrated Care
Home Health Quality Improvement Campaign
The Joint Commission

Maryland Hospital Association Webinar Slides: Improving Care Transitions between Hospital and Home Health

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.

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.

Data Analysis on measuring 30-day readmissions

  • Click here to view Medicare claims and OASIS data analysis comparing an OASIS-based 30-day readmissions measure to a claims-based measure. This Alliance-sponsored analysis was authored by Dobson, DaVanzo and Associates.