Transitions in Care-Quality Improvement Collaborative

The Transitions in Care–Quality Improvement Collaborative, or TC-QuIC, addresses one of health care’s most persistent challenges—transitions of chronically or seriously ill patients between health care settings (e.g., from hospital to rehab facility or home). The goal of the multi-provider initiative is to improve both patient care and patient, family, and staff satisfaction. TC-QuIC is an integral component of the Fund’s Next Step in Care campaign, which also includes a website with guides and materials for family caregivers and health care providers and outreach to community groups that serve family caregivers.

Fostering changes in individual and organizational practice and culture, TC-QuIC works to create better coordination and communication between health care organizations that share patients, and better integration of family caregivers in planning and implementing transition care plans. By building effective partnerships that recognize and support family caregivers and by developing better tools for critical tasks such as medication management, the initiative is helping providers avoid problems that undermine patient care and too often lead to preventable hospital readmissions.

From throughout the New York metropolitan area, hospitals, skilled nursing facilities, certified home health agencies, and a hospice (see box at right) are participating in the second round of TC-QuIC. (The first round of TC-QuIC ran from 2010 to 2011.) Through partnerships of two or more organizations, and with assistance from Fund staff and expert faculty members, the partnerships are focusing on four specific points along the transition continuum: admission, planning for discharge, handoff to the next provider, and follow-up. At each stage, they are identifying specific challenges, developing and evaluating new processes to tackle those challenges, and working toward implementing successful processes across large sections of each organization. Many of the teams are using guides and materials available on the Next Step in Care website.

For descriptions of the initiatives addressed in the first round of TC-QuIC and a listing of its participants, see the  Partnerships and Projects page.