MPRO is conducting a Care Transitions project in the mid Michigan area (specifically, Clinton, Eaton and Ingham counties) to measurably improve the quality of care of Medicare beneficiaries who transition between care settings. MPRO is focusing on improving coordination of care between providers and across the continuum of care by promoting seamless transitions from the hospital to home, skilled nurising care, home health care or other providers to prevent avoidable readmission to the hospital.
Care Transitions is the process by which patients move from hospitals to other care settings. It is increasingly problematic, and Medicare patients report greater dissatisfaction in discharge-related care than in any other aspect of care that the Centers for Medicare & Medicaid (CMS) measures.
MPRO is working with health care providers in mid Michigan to implement interventions that result in process improvements and address issues in medication management, post-discharge follow-up, communication and coordination of care. The Care Transitions project will promote increased self-management of chronic disease for patients and their caregivers through education, support and a patient health care record, as patients move across community health care settings.
