Provider: Fairview Health Services
Background: Care transitions constitute any instance in which a patient moves from one health care setting to another and are a focal point for nearly every health system. Recently, changes in the Centers for Medicaid and Medicare Services (CMS) have prioritized the need for health systems throughout the country to develop and implement programs to reduce hospital readmissions. This is especially pertinent to teams dedicated toward quality improvement as payments for Medicare patients are reduced through the Hospital Readmissions Reduction Program if hospitals have an above-average 30-day readmission rate. Fairview’s Medication Therapy Management (MTM) program, developed in partnership with the University of Minnesota, College of Pharmacy, originally began the Comprehensive Medication Management (CMM) program over 20 years ago and has since developed into an expanded network focused on reducing readmission rates throughout the system.