Awarded Two-Year Special Innovation Project – “Interventions that are Ready for Spread and Scalability”


Massachusetts office Woburn, Massachusetts (October 17, 2016) — Nursing facilities are faced with challenges when discharging patients back to the community. Ongoing management and evaluation needed after discharge to transition patients safely and successfully back into their home and community doesn’t always happen as planned. Patients returning home often do not have the information or resources needed and often end up returning to the hospital.

The Centers for Medicare & Medicaid Services (CMS) recently awarded a two year Special Innovation Project, under Healthcentric Advisors’ New England Quality Innovation Network-Quality Improvement Organization (NE QIN-QIO) five-year master contract, to address unnecessary and potentially avoidable hospitalizations through the implementation of a systematic discharge process for skilled nursing facility patients being discharged back to the community.

Healthcentric Advisors, in collaboration with Southcoast Health and Aging Services Access Point Coastline Elderly Services, Inc. (CESI), will be working with a small group of Nursing Facilities to implement a standardized discharge process, connection to available community services, and post-discharge follow up. This intervention aims to safely transition patients back into the community so they can continue their recovery at their home of choice.

Grace Dotson, RN, MS, CMAC, Director of Care Coordination, at Southcoast Health noted that we are “pleased to support and participate in this project. This is an exciting time within healthcare, as work with our community partners to develop a collaborative program that improves care transitions across settings with the needs of the patient at the center of our shared focus.”
Although similar interventions have been successfully implemented in the hospital setting, limited efforts have been focused in the nursing home environment and those that have been successful often required expensive and time consuming changes to the Electronic Health Record system. This project is different in that it’s built upon collaboration with key stakeholders and does not require EHR changes. Program finding and implementation materials will be broadly disseminated so others can benefit from these learnings.

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For media inquiries contact Alex Bronk by phone (401-528-3273) or email ([email protected]).

About Healthcentric Advisors

Healthcentric Advisors is a non-profit health care quality improvement agency providing consulting, research and education services. Located in Providence, RI with offices in Woburn, MA and Brunswick, ME and a staff of approximately 50 physicians, nurses, educators, analysts and other professionals, Healthcentric Advisors is a sought-after partner to national and local government agencies, foundations, insurers, health care providers, stakeholders and educational institutions on health care quality improvement initiatives.

About the New England QIN-QIO

The New England QIN-QIO, administered by Healthcentric Advisors in partnership with Qualidigm, works across New England on strategic initiatives such as reducing health care associated infections, reducing readmissions and medication errors, working with nursing homes to improve care for residents, supporting clinical practices in using interoperable health information technology to coordinate care, promoting prevention activities, reducing cardiac disease and diabetes, reducing health care disparities and improving patient and family engagement. The NE QIN-QIO also provides technical assistance for improvement in CMS value-based purchasing programs, including the physician value-based modifier program.

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