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Care Transitions is a Centers for Medicare & Medicaid Services quality improvement project for Texas' Lower Rio Grande Valley administered through TMF Health Quality Institute. It is a regional, collaborative effort to reduce avoidable hospitalizations by improving patient care transitions. |
| Volume 1, Issue 6 |
April 2009 |
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TMF Upcoming Webinar
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Reducing Heart Failure Readmissions Through Improved Care Transitions Wednesday, April 22, 2009 at noon CT (FREE) Learn how the basic tenets of an effective care transitions program resulted in a significant drop in heart failure readmission rates. Presented by Margie Namie, RN, BSN, MPH, CPHQ, vice president of quality, Mercy Health Partners of Cincinnati. Complete descriptions and registration information for TMF events >>
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Visit the"What's New" section of the Care Transitions Web site to access newly posted resources and tools. |
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Care Transitions News is brought to you by

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In the News |
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Unplanned Rehospitalizations Cost Medicare $17 Billion in 2004The New England Journal of Medicine found that unplanned rehospitalizations among Medicare beneficiaries are prevalent and costly. Nearly 11.8 billion, or one-fifth, of discharged patients were rehospitalized within 30 days--and half of these patients didn't see a physician after discharge.
Financial and Health Burdens of Chronic Conditions GrowOf the 72 million working-age Americans who live with chronic conditions, three in 10 live in families having problems paying medical bills. This six-page report from the Center for Studying Health System Change reviews the results from the Community Tracking Study.
Association Updates Guidelines on Heart FailureCalling it a "critical performance measure for care coordination and transition," the American College of Cardiology issued updated guidelines for the diagnosis and management of heart failure in adults. The guidelines address discharge instructions as well as patient education on activity, diet, medications and follow-up appointments, and what to do if symptoms worsen.
Poor Transitions, Coordination Pose Barriers to Quality Chronic Disease CareQuality care is impeded by poor transitions between health care facilities and lack of care coordination within the delivery system, according to "Chronic Care: A Call to Action for Health Reform," a report issued by AARP last month. Health Literacy and Patient Safety Highlighted in AHRQ PodcastThe Agency for Healthcare Research and Quality (AHRQ) monthly "Perspectives on Safety" podcast recently featured Dean Schillinger, MD, director of the Center for Vulnerable Populations at the University of California, San Francisco. Topics covered included teach-back, informed consent and health literacy measurement.
Preventing Catheter-Associated Urinary Tract Infections (CME)CMS will no longer reimburse health care institutions for care related to preventable conditions, including catheter-associated urinary tract infections, which account for about 40% of infections acquired in health care facilities. (Free Medscape registration required.)
New Survey Results Show Huge Burden of DiabetesThis national survey is the first in 15 years to include findings from the oral glucose tolerance test, which is more sensitive in identifying pre-diabetes and diabetes. Vulnerable groups, such as the elderly and minorities, continue to have high incidence rates.
Advance Care Planning from AHRQThis report from the Agency for Healthcare Research and Quality (AHRQ) discusses how physicians and other health care professionals can help their patients with advance care planning and assess patient preferences for care at the end of life.
Assessments and Best Practices in Care of Older Adults The complexity of caring for older adults requires a solid foundation of assessment skills. This library of videos demonstrating evidence-based geriatric assessment tools to help working nurses improve their skills in providing quality care specialized to this patient group.
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Hospitals Using Health IT Provide Better Care at Lower CostThe first study to directly measure physicians' use of health information technology in the hospital setting found that relatively modest increases in technology use produced dramatic results in care and costs.
IHI to Host Upcoming "Hospital to Home" Seminar in Orlando The Institute for Healthcare Improvement (IHI) will offer a transitions-themed two-day seminar in Orlando, June 15 and 16. Topics areas include enhancing communications, supporting patients and families, and improving workflow using tested strategies.
Hospitals Can Earn New Certification in Heart Failure CareThe Joint Commission, in collaboration with the American Heart Association, announced a certificate of distinction program that recognizes hospitals that make exceptional efforts to foster better quality of care for heart failure patients. |
NURSING HOMES
Nursing Home QI Group Shares Front-Line Success Stories in PodcastThe Advancing Excellence in America's Nursing Homes project has reached out to nearly half of the U.S.'s nursing homes with a widely lauded quality improvement (QI) campaign. In this podcast, organization leadership and on-the-ground staffers share how and why this effort is making a difference.
Free and Updated Interact Communications Tools TMF's Care Transitions project Web site has a full set of Interact tools designed specifically for the skilled nursing facility. Download them individually or in a complete set in a ZIP file.
The Joint Commission Announces New Leadership for LTAPThe Joint Commission recently tapped Gina Zimmerman, M.S., to lead its Long Term Accreditation Program (LTAP). Zimmerman is the former head of business development for the Commission, and she has announced that the standards for accreditation will continue to undergo revisions to improve access and reduce redundancies.
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This material was prepared by TMF Health Quality Institute, the Medicare Quality Improvement Organization for Texas, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 9SOW-TX-CT-09-32
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