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In order to assist hospitals to improve care transitions and reduce readmissions, HCIF launched in May 2010 the PAVE Project (“Preventing AVoidable Episodes: Smoothing the Way for Better Transitions”), an 18-month regional collaborative to engage healthcare providers and community-based service organizations across the continuum of care. Click here to see the agenda, presentations and other materials.


The goals of the initiative were to:

  • Reduce readmission rates by 10% over the course of the 18-month project;
  • Improve transitions of care from one provider to the next for patients being  discharged from the hospitals in our region;
  • Increase patient and family engagement in the management of the patient’s healthcare plan; and
  • Engage providers and healthcare professionals within the entire continuum of care.

Participating Organizations
There were 47 organizations that participated in the PAVE Project, including hospitals and health systems, non-acute providers, and community organizations. Click here to see the list of participating organizations.


Project Workgroups
In order to accelerate the adoption of evidence-based strategies, encourage multi-organizational innovations and experimentation, and develop at least one strategy or achievement with significant regional impact, the following three workgroups were created:

  • Medication Management
  • Personal Health Record
  • Care Transitions
As a product of their collaboration, the workgroup members developed various passports that would set standards, enable communication, and improve transitions of care among providers.

Hospital Care Transitions Passport – A document with contact information for key departments involved in care transitions at the hospitals, as well as a description of the hospital’s care transitions process, in order to improve communication between hospitals and other providers across the continuum of care.

Hospital Discharge Passport – A set of standards that incorporates all of the critical components of an effective care transition at the time of hospital discharge.

Medication Passport – A set of standards that incorporates all of the critical components of an effective, clear and concise medication reconciliation and transfer form.

Payor Passport – A document with payor contact information to be used by hospital utilization management, emergency department and discharge planning staff as a way to improve communication between hospitals and insurers.


Transitions of Care Survey Summary

Each participating hospital was asked to complete the Transitions of Care Survey at the start of the project to establish baseline measures and again at project end in order to assess the qualitative improvements in the region as a whole. The results are impressive. To see the summary results, click here.

Participating hospitals reported monthly readmission data to monitor same-hospital readmission rates in the region. Baseline measurements were taken at the start of the project to determine a regional readmission rate. Eighteen hospitals submitted enough data to be included in the analysis. Click here to see the results of the analysis.

Click here to read the December 2011 press release announcing the PAVE Project results.

For more information, please contact Patty Yurchick, Senior Director of Quality Partnerships and Initiatives, at pyurchick@hcifonline.org or 215-575-3742.