Care Transitions

Patients move between health care providers and settings as their condition and care needs change. For example, a patient might receive care from a physician in an outpatient setting, then transition to a hospital during an inpatient admission before moving on to yet another care team at a skilled nursing facility. Each of these shifts from care providers and settings is defined as a care transition.

Fourteen state Medicare Quality Improvement Organizations (QIOs) are working with communities of health care providers to coordinate care and promote seamless transitions across settings, including from the hospital to home, skilled nursing care, or home health care. QIOs are also looking to reduce unnecessary readmissions to hospitals that may increase risk or harm to patients and cost to Medicare. States working to improve care transitions include: Alabama, Colorado, Florida, Georgia, Indiana, Louisiana, Michigan, Nebraska, New Jersey, New York, Pennsylvania, Rhode Island, Texas, and Washington.

Click on the markers below to visit the Care Transitions website for each state participating in this initiative.

Care Transitions Executive Summary (PDF)

Washington Colorado Nebraska Texas Louisiana Indiana Michigan Alabama Georgia Pennsylvania New York Rhode Island New Jersey Florida map of participating QIOs