Recruit and educate provider groups and communities
Recruit communities to participate in Care Transitions Initiatives
Assist communities in developing a Coalition Charter
Educate patients through Care Transitions community initiatives
Develop a V.I. Community Quality Assessment and Performance Improvement (QAPI) Process
Share discharge planning improvement strategies/interventions to improve the discharge process and coordination of hospitals with home health, nursing home, physician office and Federally Qualified Health Centers (FQHCs)
Measure(s):
1. Reduce 30-day readmissions by 20% over three years