Improving Quality of Care Transitions Initiative

Qsource encourages community coalitions to join us in this initiative to improve the care patients receive when they move from one care setting to another. Through best practices, patient education and data analysis, we can help you avoid reimbursement penalties and eliminate gaps in healthcare services. 


Anticipated Impact

  • Reduced reimbursement penalties 
  • Improved patient satisfaction 
  • Fewer medical errors and deaths 
  • Improved communication among healthcare providers in each community 
  • Fewer adverse drug events (ADEs) 
  • Reduced emergency departments visits and hospital readmissions 

Who should get involved?

Identifying and addressing care concerns are essential in making improvement and involves incorporating the knowledge and experience from a variety of care providers, such as:

  • Health System Organizational Leaders 
  • Value-Based Purchasing Representatives 
  • Service Organization Leaders 
  • Faith Community Leaders 
  • Post-Acute Care Providers 
  • State-wide Association Leaders 
  • Local Health Department Leaders 
  • Physicians and Prescribers 
  • Urgent Care Center Leaders 
  • Academic Institution Leaders 
  • Healthcare Consumers 
  • Medicare Advantage Plan Administrators 
  • State Medicaid Plan Administrators 
  • Pharmacies 


The assistance we provide is free. 

Reduced Time and Administrative Burden 

  • Assistance with developing improved transitions in care communication strategies and workflow 
  • Sharing best practices 

Billing and Reimbursement Assistance 

  • Assistance to decrease hospitalization rates 
  • Knowledge on decreasing penalties for readmission for financial ROI 

Data and Benchmarking Assistance 

  • Data reports for peer-to-peer comparison 
  • Knowledge on how to improve patient satisfaction scores 

Free Tools, Resources and Education 

  • On-demand learning online 
  • In-person technical assistance 
  • In-service training 
  • Best practice educational resources and tools 

Improved Patient Outcomes by: 

  • Identifying problems and solutions faced by patients categorized as the most vulnerable and frequent Medicare service users 
  • Enhancing their knowledge of and access to community resources 
  • Allowing the patient’s and family’s voice to be heard 


Participation is voluntary. However, we ask that participants commit to the following: 

  • Review data to identify areas for improvement, implement key interventions that can impact hospital utilization and ADEs and to identify Medicare high-use consumers. 
  • Work within the community coalition to identify gaps in transitions of care and provide effective medication management. 
  • Collaborate with community members, local businesses, other healthcare providers and healthcare consumers to identify gaps and solutions in transitions of care and provide effective medication management.