Transitions Leadership Group Maps Patient Moves through St. Vincent’s Network Continuum

Colleen SwedbergAs groundwork for participation in CMS’s Bundled Payments for Care Improvement initiative, St. Vincent’s Health Partners (SVHP) formed a cross-functional cross-boundary Transitions Leadership Group to map what happens to patients moving along their care journeys, explains Colleen Swedberg, MSN, RN, CNL, director for care coordination and integration.

In this audio interview, Ms. Swedberg describes the structure and goals of the Transitions Leadership Group and some tools and protocols it developed to set standards for any post-acute provider wishing to join the SVHP network.

During a September 2015 webinar, Post-Acute Care Trends: Aligning Clinical Standards and Provider Demands in the Changing Landscape, now available for replay, Ms. Swedberg and Julia Portale, vice president of community services, Jewish Senior Services, share their organizations’ collaborative approaches to the evolving post-acute care market.


Length: 4:03 minutes

Empowering Patients Toward Self-Management To Reduce Readmissions

To rise to the challenge of non-compliant patients, providers should ask how they can work together to empower patients toward self-management rather than why patients are non-adherent in the first place, suggests Alicia Goroski, MPH, senior project director for care transitions for the Colorado Foundation for Medical Care (CFMC). CFMC coordinates the work of state-based Quality Improvement Organizations (QIOs), who have been working with hospitals and community providers to improve care transitions and reduce readmissions.

In this interview, Ms. Goroski describes some of the interventions focused on patients, providers or both groups that have not only lowered key Medicare readmission rates but also reduced participants’ overall admission stats.

Ms. Goroski shared lessons learned from the 14 communities that participated in the CMS care transition demonstration project and details on program rollout to over 12 million Medicare beneficiaries in 400 communities during a May 22, 2013 webinar, now available for replay Patient Engagement and Provider Collaborations Across the Healthcare Continuum to Improve Care Transitions.


Length: 5:42 minutes