Author Contributions: Dr Brock had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Brock, Irby, Archibald, Goroski, Lynn.
Acquisition of data: Brock, Irby, Archibald, Goroski.
Analysis and interpretation of data: Mitchell, Irby, Stevens, Archibald, Lynn.
Drafting of the manuscript: Brock, Mitchell, Irby, Archibald, Goroski, Lynn.
Critical revision of the manuscript for important intellectual content: Brock, Irby, Stevens, Archibald, Goroski, Lynn.
Statistical analysis: Mitchell, Stevens, Lynn.
Obtained funding: Brock, Goroski, Lynn.
Administrative, technical, or material support: Brock, Irby, Archibald, Goroski, Lynn.
Study supervision: Brock, Irby, Archibald, Goroski.
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Brock reports receiving payment for lectures from the Alliance for Home Health Quality and Innovation, Ramona VNA and Hospice, and the Lewin Group and honoraria from CHRISTUS St Vincent Regional Medical Center, George Washington University, and the Hebrew Home of Greater Washington; Ms Irby reports receiving payment for lectures from the Wisconsin Hospital Association, LeadingAge Wisconsin, and Kauffman & Associates Inc; Ms Goroski reports receiving travel/meeting expenses from the Institute for Healthcare Improvement, Texas Medical Foundation, Lilly, Insignia Health, National Quality Forum, and Health Insight and an honorarium from Lilly; Dr Lynn reports receiving travel/meeting expenses from the CMS, payment for writing or reviewing the manuscript from Colorado Foundation for Medical Care, consultancy fees from the CMS as well as from the Centre for Organizational Effectiveness, Valley Health System, and Institute for Healthcare Improvement (to her institution), and payment for lectures from numerous sources (hospitals, home health agencies, regional coalitions, VA medical centers, and national organizations).
Care Transitions Project Team Members:CMS administrators: Don Berwick, MD, MPP; Kerry Weems; Leslie Norwalk, JD; Mark McClellan, MD, PhD; Office of Clinical Standards and Quality directors: Patrick Conway, MD, MSc; Barry M. Straube, MD; Office of Clinical Standards and Quality staff: Paul E. McGann, MD; Dennis C. Wagner, MPA; Jean D. Moody-Williams, RN, MPP; William C. Rollow, MD, MPH; Stephen Jencks, MD, MPH; Traci Archibald, OTR/L, MBA; Douglas Brown, MHS; Mary Pratt, MSN, RN; Joanne Lynn, MD, MA, MS; Michael T. Rapp, MD, JD; Shari Ling, MD; Randy Poulsen, PhD; Tina Dickerson; Kimquy Kieu, MD, MPH; Pamela Frederick; Robert T. Kambic; Cynthia Pamon, RN, BSN, MBA, MS, CCM; Quality Improvement Organization Support Contractor(national coordination and support) at Colorado Foundation for Medical Care: Jane Brock, MD, MSPH; Alicia Goroski, MPH; Jason Mitchell, MS; Beth Stevens, MS; Desiree Froshaug, MS; Tom Ventura, MS, MSPH; Kimberly Irby, MPH; Laura Mankin, MA; Grant Hughes; Paula Langner, MS; Andrew Perlman, MSPH; Lihong Diao, MD, MS; Lisa Helseth; Marian Boxer, RN; Maureen O’Brien, RN, PhD; Kristine Mattivi, MS, PT; Laura Palmer, MT(ASCP); Arja P. Adair Jr, MBA; Participating QIOs leading the intervention: Alabama—Wes Smith, MD, MSHA; Dianne M. Richmond, MSN, RN; Sherrie Smith, CPHQ; Rashaan Anderson, PhD, MSPH; Evadne N. Bell-Johnson, BSN, RN, CCM; Jing Li, MS; Patricia Richetto, BSN, MSN, RN; Colorado—Arja P. Adair Jr, MBA, Risa Hayes, CPC; Hilarea Amthauer, MPH, BSN, RN; Christine LaRocca, MD; Katherine Lewandowski, MPH; Melanie N. Kaup, BA; Florida—Anthony Freedman; Susan Stone, MSN, RN; Beatriz Hernandez, MSHSA, RN, BS; Peggy Loesch, MBA, BSN, RN; Cathy Sweet, RN; Kristen Turner, MS; Debbie Muntner; Georgia—Dennis L. White; Mary Perloe, RN, MS, GNP; Mari Lou Keberly, RN; Robby Langston, MSPH; Linda Kluge, RD, LD, CPHQ; Kimberly Rask, MD, PhD; Indiana—Mary Kapur, Sandy Hampton, RN, BSN; Nancy Meadows, RN, BS; Holly Davis, MBA, MEd; Ellen Murphy, MA; Cheryl Riddell, RN; Louisiana—Gary L. Curtis, MSW; Laurie Robinson, RN, CPE, CPUR; Scott M. Flowers, MHA/MBA, CPHQ; DeeAnn Broussard; Kelly Brady, RHIA; Donna Rodrigue, MHS, RRT, CPE; Rebecca Hightower, MS, RN, CPHQ, CPE; Lisa Stansbury, MHSA; Debbie Leone; Kathy Langlois, MS; Michigan—Robert Yellan, MPH, JD; Diane Smith, RN; Donna Beebe, RN, C, BSN, FACDONA; Barbara J. Smith, LBSW, MS, CHC; Katie Brown, RN, BSN; Alyse Grossman, MPH; Lisa S. Tikkanen; Nebraska— Tina Georgy, RN, MS; Audrey Paulman, MD, MMM; Janet Dooley, RHIA, CPHQ; Ted Fraser, MS; Jennifer Geisert, RN, BSN; Sandy Kilgore, RN, BSN; Keri McDermott, BA; Paula Sitzman, RN, BSN; Rama Thummalapalli, MS, CSSBB; New Jersey—Martin P. Margolies; Andrew Miller, MD, MPH; Ya-ping Su, PhD; Joyce Pontbriand, RN, BC, MEd, CPHQ; Judy Miller, MS, RN; Suhuang Chen, MS; Sai Loganathan, PhD; Rita Pascale; Dawn Cullen, BA; Diane Babuin, MS; New York—Theodore Will; Sara Butterfield, RN, BSN, CPHQ, CCM; Christine Stegel, RN, MS, CPHQ; Shelly Glock, LNHA, MBA; Joseph O’Donnell, MA, MS; Pennsylvania—John Wiesendanger, MHA; Naomi Hauser, RN, MPA, CLNC; Donna Anderson, PhD, RN; Suzanne Fritz, RN; Michelle Popovich, RN; Colleen L. Prioletti, RN; David Wenner, DO; Donald Wilson, MD, CPE; John Bowers; Jill Manna; Krista Davis; Rhode Island—H. John Keimig, MHA; Stefan Gravenstein, MD, MPH; Rebekah Gardner, MD; Rosa Baier, MPH; Gail Patry, RN, CPEHR; Lynne A. Chase; Kristen Butterfield, MPH; Maureen Marsella, RN, BS, CCM, CPC; Nelia Silva Odom, RN, BSN, MBA, MHA, WCC; Karen D’Antonio, BS, RN; Rachel Voss, MPH; Deborah Correia Morales, MSW; Texas—Tom Manley; Jennifer Markley, RN, BSN; Karen Sabharwal, MPH; Ziyin Wang, PhD; Cindy Bigbee, RN, MSN; Janice Toreki, RN, BSN; Vanessa Andow, BHA; Mary Healy, RN; Washington—Jonathan Sugarman, MD, MPH; Selena Bolotin, LICSW; Sharon Eloranta, MD; Evan Stults; Carol Higgins, OTR(Ret), CPHQ; Karla Hall, RN, CCM; Bill Mahoney, PhD; Suzie Potter; Pam Rabe; Sen Lu Dimas, BA; Seva Kumar, MBA.
Funding/Support: This project was funded through the CMS.
Role of the Sponsor: The CMS paid for its staff and contractors, who were responsible for the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, and approval of the manuscript. The CMS leaders reviewed the manuscript and provided helpful comments.
Independent Statistical Analysis: Gary Grunwald, PhD, Department of Biostatistics and Informatics, University of Colorado School of Public Health, supervised and reviewed the final analyses reported here, which were performed by Jason Mitchell, MS, and Beth Stevens, MS, both masters-level statisticians employed by the Colorado Foundation for Medical Care, the QIO for Colorado and the QIOSC in this project.
Additional Contributions: This project depended on the coordinated efforts of hundreds of participants in the government, the QIOs, and the communities. The writing team is grateful to Thomas Nolan, PhD, Associates in Process Improvement and the Institute for Healthcare Improvement, who provided guidance in the construction and interpretation of process control charts, and Gary Grunwald, PhD, Department of Biostatistics and Informatics, University of Colorado School of Public Health, who provided statistical consultation. The implementation teams are grateful for the creative engagement of Eric Coleman, MD, MPH, University of Colorado School of Medicine, and Mary Naylor, PHD, RN, University of Pennsylvania School of Nursing, in teaching their methods and helping with adaptations. The work depended critically on leaders at the Department of Health and Human Services and the CMS, and clinicians and managers in the communities. Dr Nolan's guidance was provided without compensation. Dr Grunwald's guidance was compensated through a contract with the Colorado Foundation for Medical Care.