Patients in transition - those who are moving from one care setting to another - are at increased risk for hospital re-admission (also known as re-hospitalization). Massachusetts is currently participating in many projects to address and improve hospital readmission issues, and these efforts are largely coordinated state-wide by a collaborative called the Massachusetts Care Transitions Forum, which represents some 50 organizations throughout the Commonwealth. The forum's mission is to improve the quality of patient care transitions from any one setting to another - including home.
The Massachusetts Care Transitions Forum held a Care Transitions Seminar in April 2009 to publicly share projects and developments with providers across the continuum of care. The seminar was designed to address how the Massachusetts healthcare community might achieve the "triple win" in healthcare: care that higher quality, lower cost, and patient-centered.
The seminar included two PowerPoint presentations: one on "What Patients and Families Need" and one on "What Health Plans are Doing to Prevent Readmissions".
For more information on the Care Transitions Seminar and specific best practices for preventing readmissions , click here for an overview of the projects or one the links below to view specific presentations.
- Potentially Preventable Readmissions (PPR) Project with 3-M
- STAAR Initiative: STate Action on Avoidable Re-hospitalizations
- Interventions to Reduce Acute Care Transfers (INTERACT-II) Initiative
- MOLST Demonstration Project: Medical Orders for Life-Sustaining Treatment
- Project RED (Re-Engineered Discharge)
- Project BOOST (Better Outcomes for Older Adults through Safe Transitions
- Home Care Projects: Masspro Collaborative Project
- Business-led Projects: Dovetail Health's Pharmacist-Led Transition Services to Avoid Costly Readmissions