Readmissions & Safe Transitions

Studies show poor communication during transitions of care leads to increased rates of hospital readmissions and medical errors. In fact, nearly one in five Medicare patients discharged from Minnesota hospitals is readmitted within 30 days.   

To address this issue, hospitals and health systems across Minnesota participate in SAFE Transitions of Care. The goal of this program is to improve patient safety by standardizing and improving communication during transitions of care between hospitals and across all settings of care, including other hospitals, skilled nursing facilities, long-term care, assisted living, home health and primary care.   

With implementation of safe transitions strategies, patients should experience improved care, including fewer incidents of delayed care or redundant tests, fewer medication events or missed doses and reduced readmissions to the hospital. The program includes a road map of best practices to address patient safety gaps and a toolkit of resources to implement the recommendations.   

MHA partners with Stratis Health, the Minnesota QIN-QIO, in the Coordination of Care Initiative that supports hospitals and organizations across the continuum of care as they provide high-quality transitions for patients. MHA also participated in the Reducing Avoidable Readmissions Effectively (RARE) campaign, which aimed to prevent 4,000 avoidable hospital readmissions between July 1, 2011, and Dec. 31, 2013.   

In 2018, experts from across the state streamlined the MHA transitions resources and created a tiered transitions in care road map. It includes current best practice resources and literature to support effective systemwide practices for a culture of safe transitions; quality improvement guidelines and best practices for patient and staff education; discharge planning; and transition communication.