Why Focus on Care Transitions?

A better health system would ensure patients smoothly transition between care settings.

Effective care transitions for individuals from one setting or provider to another is necessary to improve patient experience and health outcomes while reducing avoidable, costly health care visits.

Our Work - Healthy Transitions Colorado

Healthy Transitions Colorado (HTC) is a coalition of Change Agents aimed at reducing readmissions and saving millions in health care dollars. As the managing partner HTC, CIVHC collaborates with organizations to achieve readmissions goals and enhance community care coordination. Since the official launch of the campaign in 2013, CIVHC and the HTC operating team have engaged critical health care and community partners and improved the services, education, and support provided to entities across Colorado.

Click here to visit the HTC website to learn more.

CO APCD data helps inform community partners by offering readmissions data that can be tracked over time to show improvement. Unlike other readmissions data available, which is usually focused on Medicare for specific conditions and hospital inpatient stays, information from the CO APCD can identify readmission rates to the ED and observation stays for the entire population; providing communities with a more comprehensive view of patient patterns and opportunities to partner outside the hospital.

Featured Change Agent: Regis University Graduate Student

Project Summary: Logic dictates that if a patient fully understands their hospital discharge instructions then they would be less likely to be readmitted. However, there is little formal data about the correlation between effective discharge information from the patient’s perspective and hospital readmission rates. A Regis University student evaluated CO APCD data alongside patient survey information from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) to see if such a relationship exists.

Hospital-specific 2009-2013 CO APCD data from across all lines of business (Commercial, Medicaid, and Medicare) was analyzed compared to responses to two specific HCAHPS care transitions survey questions for Colorado hospitals:

  • Whether they were given information about what to do during their recovery at home.
  • Where they ranked themselves when asked if they understood their care when they left the hospital.

Benefit to Colorado: The results of the study showed that across all diagnoses, higher rankings on the HCAHPS care transitions composites were associated with lower 30-day all cause readmission rates. Hospitals can use this information to build the case to enhance their own targeted interventions and ensure discharge instructions are communicated effectively to support healthy transitions of care.