Improving clinical performance requires smooth care transitions from inpatient to post-acute settings. Patients are often unprepared for their healthcare self-management role at home following an acute-care hospital stay. Quality and patient safety may be compromised during hospital-to-home transitions due to medical and medication errors, incomplete or inaccurate information transfer and poor or no follow-up care. This can result in readmissions to the hospital, 75% of which the Centers for Medicare & Medicaid Services estimates are preventable. The rate of patient readmissions within 30 days of discharge is being scrutinized by CMS through its Care Transitions Project now running in 14 diverse regions nationwide.
