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
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.