Health Plan Performance Improvement Project: Transitions of Care: Improved Post-Discharge Follow-up Care

Four health plans—Blue Plus, HealthPartners, MHP, and Medica—are working with hospital partners to improve post-discharge care for low-income seniors and disabled members. Efforts include a focus on discharge planning and communications for follow-up care. The project was launched in 2011 and is being evaluated by monitoring primary care appointments within 14 days of discharge.

The teams are using several tools to support effective discharge planning and follow-up, including those in the Resources section below.

Resources for care coordinators and providers

The Care Transitions Program. Under the leadership of Dr. Eric Coleman, the aim of the Care Transitions Program is to support patients and families, increase skills among health care providers, enhance the ability of health information technology to promote health information exchange across care settings, implement system level interventions to improve quality and safety, develop performance measures and public reporting mechanisms, and influence health policy at the national level.

The STate Action on Avoidable Rehospitalizations (STAAR) Initiative. This program aims to reduce rehospitalizations by engaging families, patients, providers, payers, and stakeholders.

Project RED (Re-Engineered Discharge). Strategies to improve hospital discharge processes that promote patient safety and reduce rehospitalization rates.

Contact information

For more information on PIPs, please contact Karla Weng, program manager, 952-853-8570.