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January 29, 2014
Healthy Transitions Colorado, Collective Impact in Action
By: Jolene Gurtis, MS, Senior Communications Manager, CFMC


Even with the best system in place, best coordination, and the most activated patients; no single organization can improve care transitions independently - all aspects of the community need to be involved along the continuum to really impact positive change in Coloradoans health. One solution is a collective impact approach. Collective impact is particularly applicable to the HTC campaign and actually helped get the ball rolling early in the planning stages when the campaign was just an idea.     

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There's More Than One Way to Slice an Apple - and to Calculate Readmissions
By: Kristin Paulson, Senior Manager of Policy and Initiatives, CIVHC
There's a lot of data out there, folks. Tons, in fact. One of the statistics you hear a lot about these days is hospital readmission rates. Hospitals have a lot riding on their readmissions rates and many projects across the country focus on reducing readmissions. The Colorado All Payer Claims Database now has new ways of looking at readmissions that will give hospitals and health systems deeper insights into readmissions. 
Increased Patient Education and Reducing Hospital Readmissions
By: Anna Morris, MPS - Project Director, Hospital Engagement Network, Colorado Hospital Association

Nurse patientPatient education can reduce hospital readmissions significantly. When a patient is able to understand their diagnosis and how to properly manage their condition, the patient is 30% less likely to return to the hospital within 30 days of being discharged ("Reducing Hospital Readmissions With Enhanced Patient Education").

Study Ties Hospitalizations to Dip in Food Budgets
From The New York Times, January 6th, 2014.
A new study detailed in this month's Health Affairs looked at patterns of hospitalizations for diabetic patients and found that hospitalizations among this population, especially low-income diabetics, was tied to declining food access at the end of the month. Causes of admissions are also causes of readmissions and drivers of readmission rates. (Health Affairs article requires a log on to access)
Affordable Care Act Reforms Are Leading to Lower Readmission Rates for Medicare Beneficiaries
From the CMS blog December 6th, 2014
The Centers for Medicare and Medicaid Services have released information that reforms and changes implemented in the Affordable Care Act have been directly tied to decreasing readmission rates for Medicare patients. From January 2012 to August 2013, national Medicare readmissions have dropped from over 19% to under 18%. These improvements have prevented over 130,000 readmissions over the past 18 months.
Care Transitions: 
Best Practices and Evidence-based Programs 
Center for Healthcare Research & Transformation, January 2014 

A new white paper examines evidence-based approaches to improving care transitions. The paper summarizes best practices and describes successful programs that reduced readmissions and overall costs. The paper is available through CHRT and on the HTC website on our Tools page.

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364 Hospitals Have High Rates Of Overall Readmissions, New Medicare Data Show

By Jordan Rau

From Kaiser Health News on January 6th, 2014

Eight percent of the hospitals nationwide still have higher than average rates of hospital-wide all-cause readmissions. Colorado came in as one of the top 10 states in the nation for readmissions and didn't have a single hospital that came in lower than the national readmissions average. 
CMS Data Navigator Update

The CMS Data Navigator has become a key tool in helping users connect to the vast inventory of CMS data. The tool was designed to make finding data easier, faster, and less frustrating and its success is demonstrated by the near 10,000 visitors per month that use the CMS Data Navigator. A number of enhancements were added to the latest version, released December 2013. 

In This Issue
Community Partner Perspectives: 
Rev. Nancy True, Unlimited Grace LLC

National Call to Converse about Death and End of Life Decisions

Having served as a clinical chaplain in hospice and end of life care over the past ten years, I know the struggles and the joys individuals and families experience when they are faced with a life limiting diagnosis and the need for compassionate healthcare professionals to be present during this sensitive time of transition in life.

Upcoming Events
Webinar Series: Shining Stars Across the Nation
Conference: Optimizing Medication Safety and Healthcare Quality
Call to action 

HTC is putting together a group to begin work examining patient safety efforts across Colorado. Patient safety is a critical piece of successful care transitions and we would like to expand the available resources on what is happening in Colorado. This group will be led by Donna Kasuda from Think About It Colorado. Please click here if you are interested in joining this group!

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AHRQ Focuses on End-of-life Care

The December 18 issue of the Agency for Healthcare Research and Quality's Health Care Innovations Exchange focuses on care issues at the end of life.

  • The featured Innovations describe three programs that aim to increase rates of advance care planning through education and trained facilitator, end-of-life policy work or culturally sensitive discussions of advance care directives with seniors. 
  • The featured QualityTools include a program and a Web site to help people make informed decisions about end-of-life care and services, as well as a program that offers health care professionals the tools, training, and technical assistance necessary to start successful palliative care programs.
 Healthy Transitions Colorado 
is a collaborative 
effort, focused on aligning and accelerating existing efforts to improve transitions of care for Coloradans. Our guiding principles are simple - by working together to break down the silos of health care, we can foster true community care coordination across facilities, specialties, and practices. 
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