Oct 312011

Community-based coalitions are critical to improving care transitions. To this end, people working throughout the community, in a variety of settings, really need to work to get to know one another, understand each other’s systems, and develop solutions that will translate into effective services for the community. Dr. Joanne Lynn describes a few steps to take to launch such a coalition.

Key Words: care transitions, coalition building, Section 3026, Joanne Lynn

Sep 262011

Fixing what’s wrong with care transitions will require changes in how systems work, both internally and with other systems. In this video, Dr. Joanne Lynn explains the importance of understanding your own health care system in order to fix problems in care transitions. Community and medical care providers need to work together to understand drivers in their own system before they can engineer effective solutions. You can also learn more about how to work locally by reading the Get Started guide, which you can find here:


Key words: Care transitions, quality improvement, community-based organizations

Sep 192011

What kinds of changes are needed to improve care transitions, and thereby improve patient care and experience? It is a complex issue, and requires hard work. Building the will to face and fix these problems is essential to creating a better health care system. Dr. Joanne Lynn describes how individuals and organizations can get motivated—and get started.

Jul 252011

The Long-Term Quality Alliance (LTQA) was formed to respond to the increasing demand for long-term services and support and the expanding field of providers who are delivering that care. The Alliance is working to make sure that the 11 million people who need long-term services and supports in the United States receive the highest quality of care regardless of where that care is delivered. To that end, the LTQA  and its members are deeply interested in and committed to issues surrounding care transitions—improving those transitions as a way to improve patient experience, reduce medical errors, and make care more cost-effective.

At  the  recent  2nd Innovative Communities Summit, more than 130 participants engaged in presentations and dialogue focused on learning more about how to make care transitions safe, effective, and in the best interest of patients, residents, and their caregivers.  In opening remarks, Mary Naylor, Chair of the LTQA Board of Directors, described the local, community-based solutions that are necessary to respond to breakdowns in safety and quality. She noted that the field is looking for many things, including an opportunity to learn from other communities, especially around coalition- and community-building strategies; ways to raise awareness among communities about national programs now being launched; and strategies for advancing and sustaining the kinds of learning communities that will make such improvements a reality.

Other speakers included Kathy Greenlee, Assistant Secretary for Aging, and Paul McGann, Deputy Chief Medical Officer for CMS. A full report on the day’s presentations will be released soon, with highlights that include case studies of innovative communities, resources and insights from major national endeavors, strategies for community-building, and a perspective from the philanthropic community.

The LTQA is governed by a broad-based board comprised of 30 of the nation’s leading experts on long-term care related issues. The board has representation from consumers and family caregivers, providers, health service and researchers, evaluators and quality experts, private and public purchasers of care, foundations, think tanks, and agencies of the federal government that oversee aging issues and health care quality issues.

The LTQA works to make advancements in the quality of life of people receiving long-term services and supports by:

  • Facilitating dialogue and partnerships among all provider organizations that serve people needing long-term services and supports to help break down the provider silos in which quality initiatives have occurred.
  • Bringing consumers and family caregivers together with LTC providers and government agencies to agree on goals and associated measures of greatest concern.
  • Making stronger links between quality measurement goals and evidence-based practices to achieve them.
  • Collaborating with other quality improvement organizations on common priorities and goals.

We encourage you to learn more about LTQA’s work by visiting its website at www.ltqa.org, or by emailing me at [email protected].


Key words: care transitions, coalition building, innovative communities, quality improvement

Jul 222011

Community coalitions can be an effective way to engage diverse stakeholders in achieving common goals. Establishing such coalitions to address problems in care transitions is likely to be an essential tool for ensuring that such transitions become routinely good. Shortcomings in transitions today reflect larger, systemic problems that can best be addressed by community organizations working together. Indeed, no single organization will be able to resolve the broader issues, or work on its own to improve care transitions. It will truly take a village to make transitions safe, effective, and routine.

Many organizations around the country are looking to build coalitions that focus on care transitions. For many, similar experiences building community connections will enable them to establish and lead such coalitions. But many others will need guidance and support for learning the basics of coalition building, and for understanding issues specific to care transitions.

The Center for Eldercare and Advanced Illness posted a workbook, “It Takes a Village,” that offers  community leaders ideas and pointers for how to get started – and how to get going. It can be read in its entirety on the MediCaring.org website at: https://medicaring.org/action-guides/get-started

The guide provides an overview of coalition building, ranging from recruiting partners to resolving governance. It describes what to consider when setting priorities for the work. Much of the text is devoted to issues of measurement – how will coalitions know that their work is improving patient care and experience? The guide explains how to usemeasurement to advance the coalition’s goals, how to find good data sources, and how to decide on what to measure. It provides very specific information on fixing care transitions, including how to fix the hospital discharge process and how to target rehospitalizations. Because care transitions have a major effect on very sick and vulnerable patients and families, the guide also includes ideas for how coalitions can coordinate their efforts with palliative care programs and services.

Community coalitions have proven effective at addressing diverse public health issues, from improving maternal and child health to creating healthier environments. Coalitions are defined by their focus on a particular issue, by their willingness to collaborate, and by their ability to bring a range of resources and perspectives to problem-solving. The guide offers a starting point – we hope you find it compelling and useful.

We’d like to hear about your experiences – what works for you and what doesn’t, where are your successes and what have been your challenges. Please join the dialogue by offering comments here, or emailing us at [email protected]. We look forward to hearing from you!


Key Words: care transitions, rehospitalization, readmission, quality improvement, coalition building, data sources, measurement