Working under the atom Alliance QIN-QIO contract, our Care Coordination team in Indiana collaborated with the Indiana Hospital Association (IHA) and Purdue Healthcare Advisors (PHA) to host a series of educational workshops on improving care transitions throughout the state called “Successful Hand-offs for Touchdowns in Transitions of Care.”

Care transitions occur when a patient moves from one healthcare provider or setting to another. According to the Centers for Medicare & Medicaid (CMS), nearly one in five Medicare patients discharged from a hospital (approximately 2.6 million seniors) are readmitted within 30 days, at a cost of over $26 billion every year. Hospitals have been the focus of efforts to reduce readmissions by targeting the discharge process. However, there are multiple factors along the care continuum that impact readmissions, and identifying the key drivers and other providers involved is critical for improvement.

For these workshops, we targeted the top five regions where Qsource maintains active community coalitions that report having high hospital readmission rates. Among those healthcare providers invited were primary care managers, physicians, nursing students, medical residents, extended care facilities, hospital quality/care coordinators, nursing managers, home health care and hospice care providers. We shared how, together, our organizations can improve healthcare transitions in these regions and across Indiana.

Our main goal for these workshops was to describe the process of change management for improving care transitions across the healthcare continuum. We presented an overview of root cause analysis and how to conduct interviews while correcting failed care transitions within their organizations. In addition, actual case studies were presented and the participants conducted their own analysis on each of them to identify improvement opportunities.

During the workshops, a participating provider shared their story of successfully lowering their rate of hospital readmissions through collaboration within their community. Hands-on activities were conducted in groups to teach participants about small tests of change in their settings and how to implement these processes using data collection, communication and teamwork. At the end of these events, we discussed and reviewed how to bring all these concepts together with the resources and tools included in the workshop handouts.

Partnering with the Indiana Hospital Association and Purdue Healthcare Advisors enabled us to reach a wider audience, host more workshops and spread the best practices for improving care transitions further than we could have done alone. We plan to continue and grow these successful workshops with a new series currently in development for six regions of the state.


Kara Dawson, RN, RAC-CT is the Indiana Community Manager for Qsource, a partner in the atom Alliance. She has been in nursing more than 20 years in multiple settings including hospitals, outpatients facilities and skilled nursing homes where she has held various management positions. Currently, as the Community Manager in Indiana she oversees community transitions, nursing home and antibiotic stewardship projects.