Frequently Asked Questions

What is care transitions and why is it important?
When a patient moves from one care setting to another, this is an example of a care transition. Examples include a patient moving from a nursing home to a emergency room; a patient moving from one unit of a hospital to another; a patient moving from the hospital to home under the care of a home health agency. When this transfer occurs, critical pieces of information should move with the patient to ensure that patient care is optimized. If that information does not move with the patient, care coordination can potentially be compromised and the patient’s health could be put in jeopardy. Improving care across settings and over time requires crucial contributions from all parts of the care continuum. Much effort in US healthcare delivery reform over the next decade will be spent in efforts to deliver the “right care, in the right place, at the right time.”

Rehospitalizations have emerged as a case example of hospital utilization that is potentially avoidable; many promising evidence-based and best-practice approaches demonstrate it is possible to safely and appropriately reduce 30-day rehospitalizations.

MA 30 and 15 day rehospitalization rates (and range)Data shows that 20% of all Medicare patients are readmitted to a hospital within 1 month; this number can be much higher for home health patients and nursing facility residents. This accounts for approximately $15 billion in Medicare spending; est. $25 billion across all payers annually. In Massachusetts, this equates to 377,000 hospital days totally approximately $577 million.

If Massachusetts improved its readmission rate to that of Vermont, it would save more than $96 million for Medicare.

  • 30day Overall: 10.7%                      15day overall: 7.5% (5.1-9.6%)   
  • 30day Surgical: 9.8%                      15day surgical: 6.6%
  • 30day Medical: 11.6%                     15day medical: 8.0%

How do I become part of the Galaxy meetings?
Please contact Larry Garber at Lawrence.Garber@FallonClinic.org

How do I become part of the Learning Collaborative?
Please contact Amy Boutwell at Amy@collaborativehealthcarestrategies.com.

Who is on your Advisory Committee?
Representatives from the following organizations are part of the IMPACT Advisory Committee:

Massachusetts Technology Collaborative/ Massachusetts e-Health Institute
Massachusetts Department of Public Health
Massachusetts Care Transitions Forum
Massachusetts Coalition for the Prevention of Medical Errors
Massachusetts Health Data Consortium
Massachusetts Hospital Association
Massachusetts League of Community Health Centers
Massachusetts Medical Society
Massachusetts Senior Care Association
Massachusetts Emergency Medical Services
Massachusetts Behavioral Health Partnership
Home Care Alliance of Massachusetts
Health Care For All
Community Care Linkages
Fallon Clinic/SAFEHealth
Partners HealthCare System

Why Worcester County?
Worcester County, located in central Massachusetts, was selected as the site for this project because of its racial and ethnic diversity, types of healthcare organizations, technological capabilities of these organizations, and the breadth of transition programs already in place that are addressing this problem.  Worcester County has a population of about 804,000 people over 1500 square miles.  12.6 percent of the population is over age 65, and 129,000 of the residents have a disability (16 percent).  8.6 percent are Latino, 3.9 percent are African-American, and 15 percent of the population does not speak English at home.  The per capita income is about $23,000 compared to the statewide figure of $26,000, and significantly less than neighboring Middlesex County at $31,000 (Source:  US Census, http://quickfacts.census.gov/qfd/states/25/25027.html).

Patients living in Worcester County receive approximately 85% of their healthcare within the county.  In addition, we have access to all claims data on approximately 20,000 Medicare Advantage patients living in the area from Fallon Community Health Plan, making Worcester County an ideal learning lab for this project.