A community-wide quality improvement project on patient care transitions reduces 30-day hospital readmissions from home health agencies.

Approximately 1 in 5 Medicare patients are rehospitalized within 30 days of discharge. The Harlingen Hospital Referral Region, an area defined by the Dartmouth Atlas as 35 ZIP codes in South Texas, reduced 30-day hospital readmission rates and associated costs through its participation in the Centers for Medicare & Medicaid Services Care Transitions project. The project emphasized a community-wide focus on 4 quality improvement areas: (a) the problem of rehospitalization, (b) improving cross-setting collaboration, (c) access to performance data, and (d) implementation of best practice interventions to reduce avoidable hospitalizations.