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Quality Improvement/Care Transitions


Quality Improvement Initiatives
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  • Qualaris
  • Quality accreditation


Care Transitions Initiatives
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  • Reducing readmissions
  • Improving transitions in care


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Care Transitions Collaborative (CTC)

Care transitions procedures ensure that patients move smoothly from one care setting to another. This work is being led in our region by our Care Transitions Collaborative (CTC), which is composed of leaders representing all care settings who have committed to the following vision:

A community where people transition from one health care setting to another in a coordinated, personalized manner.

CTC has identified five (5) primary focus areas:

  • Share root cause analyses/readmissions case studies (via quarterly chat forums)
  • Standardize communications using simple technology solutions for a warm handoff
  • Focus on the consumer/patient and family education
  • Provide post-acute clinical path education let by health system staff
  • Improve coordination with more attention to patient discharge logistics (such as transportation, medical equipment)

Advance Care Planning

The Advance Care Planning (ACP) Coalition, facilitated by The Health Collaborative, aims to drive breakthrough change ensuring that patients with advanced illness in our community have the opportunity to express their wishes and goals for end-of-life care, and to have those wishes honored.

The ACP Coalition is a 12-month project with 19 hospital and care partners throughout the Tri-State region. Each hospital has partnered with a non-acute care partner (skilled nursing facility, home health, etc.). Its mission is to recognize, honor, and support the end-of-life needs, wishes and goals of frail elders with advanced illness in our community.

The Goals:

  1. 75% of the defined Coalition population have a documented ACP on their record.
  2. At least 75% of the Coalition population have a successfully transferred ACP to the next care setting when they are transferred.
  3. The received ACP content is incorporated into the clinical order set at least 90% of the time.

Phase II of the Coalition will begin in August 2015.
Helpful tools: Conversations of a Lifetime

Medication Management Program/Interoperability Innovation

The NACDS Foundation Pharmacy Grant is a study that looks at the impact of Community-based Medication Therapy Management services on 30-day hospital readmission rates. This grant is a partnership between The Health collaborative, The UC College of Pharmacy, Kroger and participating hospitals. This work securely connects hospital case managers and discharge planners with their closest Kroger Pharmacist using hbDirect. Patients who are enrolled in the study receive an approximate one hour face to face counseling session with a Kroger pharmacist where a number of medication-related issues could be addressed, such as medication reconciliation, medication side effects or the patient’s ability to afford the medications. This counseling service is offered free of charge and patients do not have to fill their prescriptions at a Kroger pharmacy in order to be part of the study. The anticipated end result of this study is to be published in a widely recognized journal.