2020 M2O: Improving Care Transitions

This project is currently in process.   Final documents, resources and results will be posted.


Project Description:

Discharge planning and patient communication are frequently targeted in improvement projects, but most hospitals continue to struggle to show measurable or sustained improvement.

The MT Flex Program will provide an interactive approach for improving aspects of care transitions as well as development of a hospital and community services capabilities and resources list to aid the discharging hospital in meeting patient needs identified during the discharge process.

Project goals include: reducing readmissions, improving HCAHPS care transitions scores, improving patient outcomes, and meeting discharge planning conditions of participation (§485.642)

Project Objectives:

  • Hospitals share current discharge practices and identify gaps in practices using CMS’s conditions of participation & other identified best practices
  • Ensure all hospitals collect and communicate with the patient and/or patient representative the findings of the patient discharge evaluation including:  the discharge plan, treatment preferences, post-discharge goals and post-acute care provider
  • Compile a list of services and capabilities for each facility and resources available in their surrounding communities by identifying treatment options available that aid in the post-acute care of the patient (meets new discharge planning condition of participation)
  • Reduce readmissions through better discharge practices and improved patient communication


MT CAH Obligations and Expectations:

  • Bring together team members who commit to and are willing and excited to share discharge practices with CAH peers
  • Complete data collection on:
  • Readmissions & discharge processes
  • Hospital & Community Services, Resources & Capabilities
  • Attend and participate in virtual workshop(s) to analyze current discharge processes and discuss hospital and community services available regionally and through state partners
  • Complete simple project outline, including:  Current state analysis, issue identification, root-cause analysis, implement improvements & track results.
  • Share findings and experience during project webinars.



Jennifer Wagner, CPHQ

Rural Hospital Improvement Coordinator

Office: (406) 457-8000 |[email protected]