Improvement Projects > Integrating Care for Populations and Communities

Reducing Readmissions The goal of Integrating Care for Populations and Communities is to improve the quality of care by reducing avoidable hospital readmissions and implementing sustainable strategies through community-wide efforts. To support these efforts, Ohio KePRO is coordinating projects throughout our state, working with healthcare leaders, clinicians, community stakeholders, patients and caregivers to implement proven interventions that promote better care, better health outcomes in a cost-effective manner. We will also help communities create an infrastructure for achieving common goals.

Integrating Care for Populations and Communities Project Fact Sheet

The project is focused on rapid cycle process improvements and shared learning to reduce overall hospitalizations, improving information transfer among providers, and improving patient discharge planning. Topic areas include provider-patient interactions, system-level process improvements, with interventions that address such issues as patient-centered transition processes, identification of patients at high risk for readmission, effective communication for safe handoffs and coordination of care, prevention of adverse drug events during transitions of care, patient education and self-management, and elimination of redundant and excessive care.

Read our provider success stories (Striving for Success) to find out more about how project participants are improving community healthcare. If you are interested in participating in this project and taking advantage of federal funding for local care transition initiatives, please contact Melissa Pidhorodeckyj, Project Supervisor, at 216.503.5811 or mpidhorodeckyj@ohqio.sdps.org for more information.

Learning & Action Networks (LANs) Ohio KePRO is continuing to develop Learning & Action Networks (LANs) for all healthcare settings, interdisciplinary networks of providers and organizations collaborating to support statewide quality improvement efforts. We encourage you to click on one of the links below to read more about our existing Networks, or to join the Readmissions/Adverse Drug Events (ADE) LAN today! Members of the Network will be able to share best practices, receive up-to-date information, and collaborate with other stakeholders.

• Available LANs
• Readmissions/ADE LAN

Tools and Resources
Healthcare Professionals:

• Boost (Better Outcomes Older Adults through Safe Transitions)
• BPIP (Best Practice Intervention Package)
• Care Transitions Initiative
• Dartmouth Atlas
• HHQI
• Hospital 2 Home
• Interact II
• Project RED (Re-Engineered Discharge)
• STAAR
• SBAR
• Toolkit for Care Transitions
• Transitional Care Model
  

Seniors and Families:

• CMS Discharge Checklist
• TJC - Speak Up