Skip Navigation Archive: U.S. Department of Health and Human Services U.S. Department of Health and Human Services
Archive: Agency for Healthcare Research Quality
Archival print banner

This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: Let us know the nature of the problem, the Web address of what you want, and your contact information.

Please go to for current information.

Innovations in Care Transitions: An Overview (Text Version)

Slide Presentation from the AHRQ 2011 Annual Conference

On September 21, 2011, James Hester made this presentation at the 2011 Annual Conference. Select to access the PowerPoint® presentation (170 KB).  

Slide 1


Innovations in Care Transitions: An Overview

Jim Hester
Acting Director
Population Health Models Group
Innovation Center
Centers for Medicare & Medicaid Services (CMS)


September 11, 2011

Slide 2


  • Context
    • Care transitions as key element of health reform.
    • Overview of the CMS Innovation Center.
  • Roadmap for care transitions initiatives.
  • Some issues.

Slide 3

Why Innovate?

Slide 4

The Opportunity

Dedicated nurse case manager for high risk patients.

"The idea of the program is to keep me healthy, keep me out of the hospital and keep costs down. I don't think I would still be here without this program. It has been my lifeline."—Marie.

New York Times, June 21st 2010 An Insurer Pays more to Save

Slide 5

Innovation Center Mission

A trustworthy partner to identify, validate and diffuse new models of care and payment that improve health and healthcare and reduce the total cost of care.

Slide 6

The Innovation Center

  • Resources– $10 Billion in funding for FY2011 through 2019.
  • Opportunity to "scale up": HHS Secretary authority to expand successful models to the national level.

Slide 7

Our Work

Patient Care Models– The right care at the right time, in the right setting—every time.

Seamless Coordinated Care Models– Coordinating Care to Improve Health Outcomes for Patients.

Community and Population Health Models– Keeping families and communities healthy.

Slide 8

Measures of Success

  • Better healthcare– Improve individual patient experiences of care along the IOM 6 domains of quality: Safety, Effectiveness, Patient-Centeredness, Timeliness, Efficiency, and Equity.
  • Better health– Focus on the overall health outcomes of populations by addressing underlying causes of poor health, such as: physical inactivity, behavioral risk factors, lack of preventive care, and poor nutrition.
  • Reduced costs– Lower the total cost of care resulting in reduced monthly expenditures for each Medicare, Medicaid or CHIP beneficiaries by improving care.

Slide 9

Our Process

  • Solicit ideas for new models.
  • Select the most promising model.
  • Test and evaluate the models.
  • Spread successful models.

Slide 10

II. Partnership For Patients: Roadmap For Care Transitions

New nationwide public-private partnership to tackle all forms of harm to patients. Our goals:

  • 40% Reduction in Preventable Hospital Acquired Conditions over three years
    • 1.8 Million Fewer Injuries.
    • 60,000 Lives Saves.
  • 20% Reduction in 30-Day Readmissions in Three Years
    • 1.6 Million Patients Recover Without Readmission.
  • $35 Billion Dollars Saved in Three Years.

Slide 11

Care Transitions: The Problem

  • Transitions from one source of care to another have high risk for communications failures, procedural errors, and unimplemented plan.
  • People with chronic conditions, organ system failure, and frailty are at highest risk because their care is more complicated and they are less resilient when failures occur.
  • Strong evidence shows that we can significantly reduce hospital readmissions caused by flawed transitions.

Slide 12

Why are people readmitted?

Provider-Patient interface

Unmanaged condition worsening.
Use of suboptimal medication regimens.
Return to an emergency department.

Unreliable system support

Lack of standard and known processes.
Unreliable information transfer.
Unsupported patient activation during transfers.

No Community infrastructure for achieving common goals.

Slide 13


  • A care system in which each patient with complex needs has a care plan that:
    • Guides all care.
    • Moves with the patient across settings of care and time.
    • Reflects the priorities of patient and family.
    • Meets the needs of persons living with serious chronic conditions.

Slide 14

Safe, Effective Transitions Require:

  • Patient and caregiver involvement.
  • Person-centered care plans that are shared across settings of care.
  • Standardized and accurate communication and information exchange between the transferring and the receiving provider.
  • Medication reconciliation and safe medication practices.
  • The sending provider maintaining responsibility for the care of the patient until the receiving clinician/location confirms the transfer and assumes responsibility.

Slide 15

Care Transitions: The Approach

  • Build on evidence from research and pilots.
  • Support existing local coalitions of hospitals, nursing homes, physicians, home health, consumer groups, and other stakeholders.
  • Encourage formation of new coalitions where needed.
  • Provide data, technical support, payment mechanisms, consumer information and training to move toward seamless transitions.

Slide 16

Care Transitions: Strategy

  • Create a broad based public/private partnership.
  • Tailor support to where providers are in their quality journey—match support to needs:
    • 'Walkers': little track record, but interested in starting e.g. using QIO or AoA programs.
    • 'Joggers": proven track record, eligible for S 3026.
    • 'Marathoners': established, mature coalitions eligible for S 3022 ACO support.
  • Build a national network of 2600 community focused care transition coalitions which partner hospitals with community resources.
  • Create a 'roadmap' to help guide partnerships on their journey.

Slide 17

Care Transitions Initiatives

Slide 18

"Walkers": Administration on Aging

Slide 19

"Walkers": Quality Improvement Organizations

  • In 2008, QIOs launched community-based Care Transitions projects in 14 areas to pioneer new ways to bring communities and care teams together to reduce readmissions for Medicare beneficiaries.
  • Resources including a comprehensive toolkit and information on care transitions learning sessions can be found at .
  • Many QIOs will continue in their next contract cycle (beginning 8/1/11) to give focused technical assistance to support communities nationwide in strengthening care transitions.

Slide 20

Lessons Learned from the 14 Communities in the QIO 9th SOW Care Transitions Theme

  • Importance of community collaboration:
    • Providers talking, visiting each other, sharing.
  • Tailor solutions to fit community priorities:
    • Community needs determine change.
  • Include patients and families:
    • Incorporate beneficiaries when they are sick and healthy.
  • Public outreach activities:
    • Storytelling to support data.

Slide 21

"Joggers": Community-based Care Transitions Program (CCTP)

  • The CCTP, mandated by section 3026 of the Affordable Care Act, provides the opportunity for community based organizations to partners with hospitals to improve transitions between care settings:
    • $500 million available for community-based organizations.
    • Applications now being accepted and awarded on a rolling basis.
  • The goals of the Community-based Care Transitions Program are to:
    • Improve transitions of beneficiaries from the inpatient hospital setting to home or other care settings.
    • Reduce readmissions for high risk beneficiaries.
    • Document measurable savings to the Medicare program.
  • Learn more:

Slide 22

"Marathoners": The Medicare Shared Savings Program

  • Section 3022 of the Affordable Care Act requires the Centers for Medicare & Medicaid Services (CMS) to establish a shared savings program to facilitate coordination and cooperation among providers to improve the quality of care for Medicare fee-for-service beneficiaries and reduce unnecessary costs.
  • The Shared Savings Program is designed to improve beneficiary outcomes and increase value of care by:
    • Promoting accountability for the care of Medicare fee-for-service beneficiaries.
    • Requiring coordinated care for all services provided under Medicare Fee-For-Service.
    • Encouraging investment in infrastructure and redesigned care processes.
  • Eligible providers, hospitals and suppliers may participate in the Shared Savings Program by creating or joining an Accountable Care Organization, also called an ACO.

Slide 23

III. Some Issues for Care Transitions

  • How to build an effective partnerships?
    • Public/private.
    • Hospital/CBO.
  • How to develop and implement broader measures of effective care transitions?
  • What are the key elements of a care plan?
  • What payment policy changes are required to sustain better care transitions?
Page last reviewed October 2014
Internet Citation: Innovations in Care Transitions: An Overview (Text Version): Slide Presentation from the AHRQ 2011 Annual Conference. October 2014. Agency for Healthcare Research and Quality, Rockville, MD.


The information on this page is archived and provided for reference purposes only.


AHRQ Advancing Excellence in Health Care