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Through a Glass Darkly: The Community-Based Care Transitions Program Evaluation
By Joanne Lynn and Sarah Slocum “All models are wrong, but some are useful”. – George Box In late November, the Centers for Medicare and Medicaid Services (CMS) released an extensive evaluation of the...
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Reaching Rural Residents: Improving Care Transitions in Western New York State
The P2 Collaborative of Western New York represents a different spin on the Community-based Care Transitions Program (CCTP) model. It is unique in its focus on a very rural area of Western New York,...
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A Dangerous Malfunction in the Measure of Readmission Reduction
By Joanne Lynn and Steve Jencks Work to reduce readmissions has started to yield remarkable improvements in integration of care for frail elderly people – by prompting hospital personnel to talk with...
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The Evidence That the Readmissions Rate (Readmissions/Hospital Discharges) Is...
By Joanne Lynn M.D. [Also see companion post by Stephen F. Jencks, M.D., M.P.H.] Care transitions improvement programs have been effective in helping the health care system both become more effective...
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Protecting Hospitals That Improve Population Health
by Stephen F. Jencks, M.D., M.P.H. [Also see companion post by Joanne Lynn, M.D.] Issue. The Medicare Readmission Reduction Program (MRRP) encourages hospitals to reduce readmissions within 30 days of...
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SAGE: Bridging the Divide between Acute Medical Care and Social Services in...
By Dr. Kyle Allen and Susan Hazelett The Summa Health System/Area Agency on Aging, 10B/Geriatric Evaluation Project(SAGE) is a collaboration between an integrated health system and the local Area...
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Dr. Joanne Lynn Highlights Project RED to Improve Discharge Planning
Dr. Joanne Lynn describes Project RED (Re-Engineered Discharge), a program developed by Dr. Brian Jack and his colleagues at Boston University. It is designed to help hospitals to re-engineer their...
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Southwest Ohio Care Transitions Collaborative Talks to Medicaring about CCTP...
The Southwest Ohio Care Transitions Collaborative, one of 7 sites chosen by the Centers for Medicare and Medicaid for the first cohort of 3026 funding, had lots going for it as it pulled together a...
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Dr. Joanne Lynn on the Need for Rapid Follow-up Post Discharge
Patients just discharged from the hospital urgently need rapid follow-up in the community. Dr. Joanne Lynn describes the care coordination needed among patients, community providers, hospitals, and...
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Early Days: Chicago-Based CCTP Program Describes The Work To Date
CJE SeniorLife, a community-based organization that serves some 18,000 older adults annually, is among the first cohort of recipients for Section 3026 or Community-Based Care Transition Program...
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