Transitions of Care & Readmissions
The Centers for Medicare & Medicaid Services (CMS) defines a transition of care as the movement of a patient from one setting of care to another. Settings of care may include hospitals, ambulatory primary care practices, ambulatory specialty care practices, long-term care facilities, home health, and rehabilitation facilities. Transitions increase the risk of adverse events due to the potential for miscommunication as responsibility is given to new parties. Hospital discharge is a complex process representing a time of significant vulnerability for patients. Safe and effective transfer of responsibility for a patient’s medical care relies on effective provider communication with patient comprehension of discharge instructions. (AHRQ Care Coordination Chartbook)
Tools & Resources for Successful Care Transitions
CMS Care Compare
Recent Conditions of Participation for Discharge Planning include a requirement to use and share data to assist in selecting post-acute providers. Data must be relevant and applicable to patient’s goals of care and treatment preferences.
All CMS “Compare” sites were grouped under Care Compare as of 12/1/2020.
Resources & Tools
These resources, tools, and organizations played a vital part to inform work done in the M2O 2020 Transitions of Care Project.
Montana Community Resources
Communicating resources for patients that address social, behavioral and other needs is vital to prevent readmissions and give the patient complete, holistic care.
Assessing the patient social and behavioral health needs is an integral part of a careful discharge and may help prevent potential readmissions. Montana hospitals can use the resources here to build a their own community resource guides.
Montana Communities Resource Directory (Montanans with Medicaid)
Montana 2-1-1 provides information and connects people to resources for non-emergency needs, via an easy-to-remember phone number (2-1-1) and a website (montana211.org). Resources include: COVID-19, Food, Housing & Shelter, Income & Employment, Service Members & Veterans, Crisis & Emergency, Aging & Senior Services, Mental Health, Health & Medical, Children & Families, Education, Legal Services, Transportation, Addictions, Disability Services.
Linking Infants & Families to Supports - LIFTS (Health Mothers Health Babies of Montana)
LIFTS, or Linking Infants & Families to Supports, was created to link Montana families who are expecting or raising young ones to supports, resources, and other families. There are several ways to connect and find the information you need.
This website is your destination for the LIFTS Online Resource Guide. Here you will find detailed information on services, including relevant contact information and locations, as well as family friendly events in your area. It’s completely searchable! We hope that LIFTS will become a reliable tool on your parenthood journey to help you find what you need, when you need it, because none of us were ever meant to do this on our own.
CONNECT MT Provider Referral System
CONNECT is a secure, web-based system for sending and receiving referrals. Agencies are brought together under a single information sharing agreement Memorandum of Understanding (MOU) and Release of Information (ROI) that is HIPAA, FERPA, 42CFR and IDEA compliant. The system was created in 2009 from client advocacy and a desire to increase linkages to external resources. The current version was launched in September 2019 and includes enhanced referral features, along with robust data collection and reporting capabilities. Strategic referral tracking via CONNECT aims to improve the referral process in our communities by establishing accountability and improving processes for the exchange of client information. The ultimate goal is to foster collaborative culture among service providers in Montana.
Chronic Disease & Health Promotion Bureau
Public health enhances quality of life in Montana by supporting healthy living in your community. It touches everyone in Montana – from birth to death. Take a closer look at what public health programs are available in your community to make your life better and See Public Health Differently.
Mental Health Provider search engine for Montana.
Montana Medical Home Portal
The Medical Home Portal is a unique source of reliable information about children and youth with special healthcare needs (CYSHCN), offering a “one-stop shop” for families, physicians and medical home teams, and other professional care givers.
Montana Medical Home Portal Services Directory
This database includes services offered by non-profit organizations and a growing number of private, professional services. To create or access your own lists of local service providers that can be shared with others, printed, copied, and modified, please first sign in or register.
Community Health Resource Data Hub
The Community Health Resource Data Hub is an interactive map displaying the top needs found in each community by hospital and public health department, in addition to health and wellness resources across the state.
Big Sky Care Connect Health Information Exchange
BSCC is Montana’s statewide Health Information Exchange (HIE). Healthcare organizations of all types across Montana have the opportunity to participate in the HIE. BSCC allows participating physicians, insurance providers, public health teams, and other healthcare organizations to connect and share information through a centralized digital network
Montana Health Justice Partnership
The Montana Health Justice Partnership is a collaboration between MLSA, the Montana Primary Care Association, and six Community Health Clinics located throughout Montana. The partnership provides legal assistance to patients in some of Montana’s most vulnerable communities, working to solve legal issues that impact patient health – such as unsafe housing, family violence, and denial of earned benefits.