Overview
The Care Transitions Collaborative is a three year pilot program awarded to LHCR by the Centers for Medicare & Medicaid Services (CMS) that focuses on reducing unnecessary readmission to hospitals that may increase risk or harm to patients and cost to Medicare.

LHCR will promote seamless transitions from the hospital to home, skilled nursing care, home health care or hospice.  Process improvements will address medication management, post-discharge follow-up, and plans of care for patients who move across health care settings.

Opportunity for Quality Improvement
The process by which patients move from hospitals to other care settings is increasingly problematic as hospitals shorten lengths of stay and as care becomes more fragmented. Improved health care processes at and after discharge correlate with substantial reductions in early rehospitalization for particular conditions, such as heart failure. In addition, prior and ongoing LHCR work has assisted providers in analyzing data and in identifying and addressing gaps in care in areas such as transitions and end-of-life planning and care.